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Home , Anal fissure, Blood in stool, Orthostatic hypotension, Pruritus ani, Psoas sign, Retroperitoneal bleeding

CHAPTER 5 – GASTROINTESTINAL SYSTEM

First Nations and Inuit Health Branch (FNIHB) Clinical Practice Guidelines for Nurses in Primary Care. The content of this chapter was revised October 2011.

Table of Contents

ASSESSMENT OF THE GASTROINTESTINAL SYSTEM...... 5–1 EXAMINATION OF THE ...... 5–2 COMMON PROBLEMS OF THE GASTROINTESTINAL SYSTEM...... 5–4 ...... 5–4 ...... 5–5 ()...... 5–8 ...... 5–11 Diverticular Disease...... 5–15 ...... 5–15 ...... 5–16 Dyspepsia...... 5–17 ...... 5–18 ...... 5–21 or Cholangitis...... 5–21 Gastroesophageal Reflux Disease (GERD)...... 5–22 ...... 5–24 ...... 5–26 ...... 5–28 (PUD)...... 5–30 EMERGENCIES OF THE GASTROINTESTINAL SYSTEM...... 5–31 Abdominal (Acute)...... 5–31 ...... 5–34 Gastrointestinal (Upper and Lower)...... 5–36 Obstruction of the Small or Large Bowel...... 5–38 (Acute)...... 5–40 SOURCES...... 5–42

Clinical Practice Guidelines for Nurses in Primary Care 2011

Gastrointestinal System 5–1

ASSESSMENT OF THE GASTROINTESTINAL SYSTEM

The following characteristics of each symptom should be elicited and explored: –– History of acute (Viral – A,B,C, –– Onset (sudden or gradual) Epstein-Barr, alcohol/drug induced) –– Chronology –– History of chronic diseases –– Current situation (improving or deteriorating) –– Scleral icterus –– Location –– Yellow skin tones –– Radiation –– Tea-coloured urine –– Quality –– Clay-coloured bowel movements –– Timing (frequency, duration, pattern) –– Itchy skin –– Severity –– Precipitating and aggravating factors –– Relieving factors –– Solids or liquids –– Associated symptoms –– Site where food gets stuck –– Effects on daily activities –– Food is regurgitated –– Previous diagnosis of similar episodes –– Food/medication intake history –– Previous treatments –– Sensation that food is stuck, but improves –– Efficacy of previous treatments with eating

CARDINAL SYMPTOMS Other Associated Symptoms In addition to the general characteristics outlined –– Fever above, additional characteristics of specific symptoms –– Malaise should be elicited, as follows. –– –– Dry skin –– Dehydration Ask about all of the characteristics (see “Assessment –– Dry mouth of the Gastrointestinal System”). –– Diet recall, appetite and foods avoided (including reasons for avoidance) and –– Meal pattern (for example, small, frequent meals) –– Frequency, amount –– Anorexia –– Presence of bile –– Recent weight loss or gain that is not deliberate –– Presence of and its colour (for example, bright red, dark, colour of coffee grounds) MEDICAL HISTORY Gastrointestinal: Bowel Habits –– (gastroesophageal reflux –– Usual and changes in the frequency, colour, disease [GERD], Barrett’s , toxic ) consistency of stool –– Gastric/duodenal disease (gastric ulcers, diabetic –– Changes in the diameter of stool , hiatus hernia, peptic ulcer disease) –– Presence of blood or –– Gallbladder disease (biliary colic, cholelithiasis, –– Pain before, during or after defecation choledocholithiasis, cholecystitis) –– Sense of incomplete emptying after bowel –– (hepatitis, chronic diseases, ) movement –– (pancreatitis) –– Tenesmus –– Small/large bowel disease (inflammatory –– Use of bowel disease, ischemic , diverticulosis/ –– History of hemorrhoids, anal fissure diverticulitis, polyps, history of bleeding) –– Belching, and –– Functional bowel problems (irritable bowel syndrome [IBS], constipation, previous obstruction)

Clinical Practice Guidelines for Nurses in Primary Care 2011 5–2 Gastrointestinal System

–– Rectal/anal disease (anal fissure, ) –– Cardiac disease –– Presence of hernia, masses –– Renal disease –– Blood transfusion –– Abdominal neoplasm PERSONAL AND SOCIAL HISTORY (SPECIFIC TO GASTROINTESTINAL SYSTEM) –– Abdominal surgery –– Past and current use of medications, supplements, –– Alcohol use herbs (for example, nonsteroidal anti-inflammatories, –– Smoking estrogen, progesterone, calcium channel blockers, –– intake , antacids, , thiazide –– Use of street drugs, including injection drugs , steroids, digoxin, azathioprine) –– Use of anabolic steroids Nongastrointestinal considerations (may cause –– Travel to area where infectious gastrointestinal gastrointestinal illness/symptoms): conditions are endemic –– Body piercing or tattoos –– (myocardial infarction, congestive heart failure, , ) –– Stress at work, home or school –– Renal disease (polycystic kidneys) –– Dietary intake of nitrates (for example, smoked foods) –– Gynecologic conditions (pregnancy, endometriosis, ovarian cysts) –– Diet (including wild game) –– Obesity FAMILY HISTORY (SPECIFIC TO –– Intake of untreated water GASTROINTESTINAL SYSTEM) –– Sanitation problems at home or in the community –– Alcoholism –– Sexual practices –– Any history related to the gastrointestinal system (see “Medical History”) OCCUPATIONAL OR SCHOOL ENVIRONMENT –– Household contact with , food –– Health care occupation poisoning –– Institutional environment – workers or residents –– Metabolic disease (for example, mellitus, (for example, nursing home) ) –– Environmental exposure –– Chemical exposure

EXAMINATION OF THE ABDOMEN

–– Apparent state of health ABDOMINAL INSPECTION –– Appearance of comfort or distress –– Abdominal contour, symmetry, scars, dilatation –– Preferred position of comfort (supine, sitting of forward, lying on side) –– Movement of abdominal wall with respiration –– Colour (for example, flushed, pale, jaundiced) –– Visible masses, , pulsations, peristalsis –– Nutritional status (obese or emaciated) –– State of hydration (skin turgor) AUSCULTATION –– Match between appearance and stated age Auscultation should be performed before percussion and palpation so as not to alter bowel sounds. VITAL SIGNS –– Presence, character and frequency of bowel sounds –– Temperature and pulse –– Presence of bruits (renal, iliac or abdominal aortic) –– Respiratory rate ––

2011 Clinical Practice Guidelines for Nurses in Primary Care Gastrointestinal System 5–3

PERCUSSION CARDIOVASCULAR AND PULMONARY EXAMINATION –– Percuss from resonant to dull areas –– Liver: define upper and lower borders, measure A cardiovascular and pulmonary exam should also span (normal: 6–12 cm in the mid-clavicular line) be performed. –– Spleen: confirm presence of normal resonance –– Heart sounds over lowest rib interspace in anterior axillary line –– Lungs (crackles, bronchial breath sounds in –– Bladder: identify distention and fullness lower lobes) –– Identify other areas of dullness, increased –– Peripheral pulses (may be altered or asymmetric resonance or tenderness with aortic ) –– Assess for ballotment if suspect –– In , vital signs and refill may be altered LIGHT PALPATION –– Abdominal pain (may be referred from the lungs –– Tenderness, muscle guarding, rigidity in pneumonia, heart in myocardial infarction) –– Superficial organs or masses Considerations for the Elderly DEEP PALPATION –– Classic symptom patterns for disease are not –– Tender areas, rebound tenderness reliable with older adults due to decreased pain perception, comorbid conditions and reduced organ –– Liver: size, tenderness, whether edge is smooth function due to the aging process or irregular, firm or hard –– Tend to present later in the course of the illness –– Spleen: enlargement, tenderness, consistency –– Symptoms may be nonspecific and/or poorly –– Kidney: tenderness, enlargement, tenderness localized, complicating differential diagnosis of ostovertebral angle –– More likely to have cognitive deficits and/ –– Masses: location, size, shape, mobility, tenderness, or alterations in mentation at presentation, movement with respiration, pulsation, hernias complicating assessment and diagnosis (midline, incisional, groin) –– and confusion common with constipation, –– Inguinal lymph nodes: enlargement, tenderness inadequate hydration, secondary to –– Femoral pulses gastrointestinal blood loss : –– May have absence of fever, even with serious PERIPHERAL AREAS infection –– Have decreased pain perception so may not have –– Jaundice (scleral icterus, skin) classic presentation of an –– Spider nevi on face, neck or upper trunk –– At higher risk for certain conditions and –– Palmar erythema, Dupuytren’s contracture complications to conditions due to the aging (both associated with chronic liver disease) process (cardiovascular disorders [abdominal –– Clubbing of fingers (late sign associated with , mesentary ischemic disease], inflammatory bowel disease, cancer) gallbladder disease, , peptic ulcer disease, constipation) –– Consider prostate screening in males > 50 by –– For occult blood (which would indicate digital rectal exam (DRE) and/or prostate specific gastrointestinal [GI] bleeding) antigen (PSA) test1 –– For referred pain (which occurs in appendicitis) –– For masses, hemorrhoids, anal fissures, sphincter tone, etc. –– Prostate exam in males (size, consistency, tenderness)

Clinical Practice Guidelines for Nurses in Primary Care 2011 5–4 Gastrointestinal System

COMMON PROBLEMS OF THE GASTROINTESTINAL SYSTEM

ANAL FISSURE2,3,4 –– Sexually transmitted infections (HIV/AIDS, ) Painful, linear tear in anal mucosa. –– Ano-rectal malignancy –– Tuberculosis CAUSES –– Leukemia –– Chronic constipation –– Proctitis –– Trauma to (from hard stool, anal intercourse, foreign object) COMPLICATIONS –– of Crohn’s disease, , –– Constipation HIV/AIDS, syphilis, leukemia, tuberculosis, cancer –– Chronic anal fissure Once an anal tear occurs, a pattern of repeat injury –– Secondary sphincter and pain occurs from anal sphincter spasm that retracts the edges impairing healing and repeat injury DIAGNOSTIC TESTS with defecation which may lead to a chronic fissure. –– None Suspect an underlying etiology for the fissure when the wound does not respond to therapy. MANAGEMENT

HISTORY Goals of Treatment –– Acute pain during and after defecation (pain –– Relieve pain, sphincter spasm may be severe, often described as “tearing”) –– Promote healing –– Pain may persist for several hours post-defecation –– Relieve underlying constipation –– Spotting of bright red blood with defecation –– Prevent recurrence –– Bleeding tends to be minimal (often only seen –– Prevent stricture formation on toilet paper after wiping) –– Perianal itching or irritation Nonpharmacologic Interventions –– Constipation caused by fear of pain –– Most acute fissures are superficial and will –– Tends to occur in young and middle-aged adults heal spontaneously over 4–6 weeks –– Most common cause of chronic perianal pain –– Sitz baths 3 or 4 times daily for 20 minutes with warm salt water PHYSICAL FINDINGS To examine anal area, have client lie on left side Client Education with the drawn up to the chest. Firmly retract –– Instruct client about proper perianal hygiene buttocks to adequately visualize anal tissues. and prevention of infection –– Counsel client about lifestyle and diet –– Overlying anal mucosa may conceal (increase dietary fibre, fluids, exercise) –– Acute fissure appears like a fresh laceration –– Swelling, , fibrosis or sphincter muscle Pharmacologic Interventions visualized at wound base (chronic fissure) Reduction of Local Pain and Discomfort –– Usually one fissure, at posterior midline (suspect other underlying diagnosis if not midline or Local topical preparations without corticosteroids if multiple) may be useful: –– Digital rectal exam causes acute pain zinc sulfate ointment (Anusol), bid and after each bowel movement DIFFERENTIAL DIAGNOSIS An ointment is better than a suppository because –– Thrombosed external hemorrhoids it remains within the affected area. –– Perianal or perirectal –– Inflammatory bowel disease (Crohn’s disease, ulcerative colitis)

2011 Clinical Practice Guidelines for Nurses in Primary Care Gastrointestinal System 5–5

Promote Healing, Reduce Ongoing Injury with Stools –– Systemic sclerosis stool-bulking agents and stool softeners –– Bowel strictures (secondary to inflammatory (see “Constipation”, “Pharmacologic Interventions”) bowel disease, post-surgical) –– Endocrine disorders (hypothyroidism, diabetes Monitoring and Follow-Up mellitus, panhypopituitarism) Follow up in 1–2 weeks. –– Neurogenic disorders (, Hirschsprung’s disease, Chagas’ disease, intestinal Referral pseudo-obstruction, multiple sclerosis, spinal cord injury, Parkinson’s disease) Arrange consultation with a physician if fissure does not heal in 4–6 weeks, chronic history of fissure, client MEDICATIONS ASSOCIATED is experiencing intolerable pain, non-midline position, WITH CONSTIPATION history of or suspected inflammatory disease or other underlying causative disorder. –– Amantadine –– Antipsychotics CONSTIPATION5,6,7,8,9,10,11,12,13,14,15,16,17,18 –– Anticholinergics –– Antihistamines (first generation) According to the Rome III criteria for functional –– Anticonvulsants (for example, phenytoin, bowel disorder, constipation is defined by the carbamazepine) presentation of two or more of the following –– Cation-containing agents (for example, aluminum symptoms for at least 12 weeks with onset at least antacids, calcium supplements, preparations) 6 months prior to diagnosis:17,19 –– Calcium channel blockers –– Less than 3 stools per week –– Diuretics –– During at least 25% of defecations there is any –– Nonsteroidal anti-inflammatory drugs (NSAIDs) one or more of: –– analgesics –– straining –– Pseudoephedrine –– lumpy or hard stools –– Tricyclic –– sensation of incomplete emptying of –– sensation of blockage/obstruction at the HISTORY anorectum Constipation is a symptom, not a diagnosis, and a –– use of manual maneuvers to pass stool careful, accurate history and (for example, digital extraction, supporting is important to identifying the underlying causes. pelvic floor) –– Routine bowel habits In addition: Loose stools are rarely present without –– Duration of constipation (recent or chronic problem) use. The criteria for irritable bowel syndrome –– Recent change in pattern of defecation, consistency (see “Irritable Bowel Syndrome”) are not met . of stool CAUSES –– Frequency of bowel movements –– Difficulty in passing stool (straining, manual –– Ignoring urge to defecate (habitual, to avoid manipulation, sensation of obstruction/blockage, discomfort from hemorrhoids or anal fissure) incomplete emptying) –– Insufficient fibre and fluid in diet –– Any associated rectal blood (hemorrhoids) –– Poor bowel habits –– Diarrhea (overflow) –– Physical inactivity –– Abdominal pain, cramping and bloating and –– Pregnancy relationship to bowel function –– Side effects of medications –– Pain on defecation (hemorrhoids, anal fissure) –– Abuse of laxatives –– Tenesmus –– Cancer of colon or rectum –– Time of most recent bowel movement –– Large bowel disorder (slow transit, dyssynergenic –– Fluid intake defecation, irritable bowel syndrome) –– Dietary intake (fibre content) –– Myotonic dystrophy –– Activity and exercise patterns

Clinical Practice Guidelines for Nurses in Primary Care 2011 5–6 Gastrointestinal System

–– Current medication, previous and current use COMPLICATIONS of laxatives –– Chronic abdominal pain –– Presence of emotional stress, or depression –– Hemorrhoids (especially in the elderly) –– Anal fissure –– Eating disorders –– –– Pregnancy (current) –– Fecal and urinary incontinence –– Endocrine disorders (for example, diabetes –– Urinary retention mellitus, hypothyroidism) –– from straining –– Neurological disorders (for example, Parkinson’s disease, multiple sclerosis) –– Intestinal obstruction –– Collagen vascular disorders (for example, systemic DIAGNOSTIC TESTS sclerosis) –– Client’s understanding of normal bowel function –– Test stool for occult blood –– Measure PHYSICAL FINDINGS MANAGEMENT –– Usually no distress –– Client looks well Goals of Treatment –– Abdomen may be distended, may be tympanic –– Establish regular bowel function on percussion –– Eliminate contributing factors –– Bowel sounds normal but may be reduced –– Identify and manage underlying disease in chronic constipation –– Prevent and treat complications (for example, –– Bowel sounds normal to dull in left lower quadrant; fecal impaction, hemorrhoids, anal fissures, rectal sometimes similar findings in right lower quadrant prolapse, , bowel obstruction) –– Stool may be palpable in left or right lower quadrant –– Eliminate need to strain and prevent adverse effects –– Left and right lower quadrant may be tender of straining (for example, hernia, gastroesophageal –– Hard, pebbly stool in rectum, or rectum may reflux, coronary and cerebral dysfunction in be empty the elderly) –– Hemorrhoids or anal fissures may be present Nonpharmacologic Interventions DIFFERENTIAL DIAGNOSIS –– Ensure fluid intake of 1.5–2 L/day –– Irritable bowel syndrome –– Dietary fibre intake of 20–30 g/day: bran, –– Diverticular disease whole grains, fruits and vegetables, prune juice, –– Partial bowel obstruction stewed prunes and figs can be tried –– Rectal fissure –– Discontinue medications with constipating effects –– Anal fissure or hemorrhoids if possible –– Physical inactivity –– Minimize use of laxatives –– Cancer of colon, rectum or other organ –– Encourage relaxation exercises for the pelvic –– Diseases of the large bowel floor and external anal sphincter muscles –– Endocrine problems (for example, hypothyroidism) Client Education –– Neurological diseases (for example, Parkinson’s –– Explain what constipation is and ways of disease) preventing it –– Reinforce the importance of passing stool when urge presents, as ignoring the urge decreases the sensitivity to the sensation over time –– Encourage establishing a bowel routine of toileting after meals when colonic activity has been stimulated to help develop a conditioned reflex for bowel action (early morning after breakfast is the best time)

2011 Clinical Practice Guidelines for Nurses in Primary Care Gastrointestinal System 5–7

–– Avoid prolonged straining on toilet Chronic Constipation –– Encourage increased physical activity for sedentary The following medications may be used in older clients conjunction with nonpharmacologic approaches –– Advise client that bowel retraining may take Step 1: Suggest a bulk-forming agent (must be taken months (patience and persistence are required with adequate fluids): and dietary changes must be maintained over the long term) psyllium (Metamucil), 1 tsp (5 mL) in 8 oz (250 mL) fluid PO 1–3 times daily Pharmacologic Interventions The patient can obtain Metamucil with a prescription To relieve initial constipation, medications may be through an NIHB pharmacy provider. required. Avoid starting client on a long-term course Begin bulk-forming agents with a single daily dose of laxatives. and increase frequency of dose every 2–3 days as tolerated. Acute Constipation If client needs urgent relief, use osmotic laxative agents: Step 2: If client needs more urgent relief, add osmotic laxative agents: magnesium hydroxide (Milk of Magnesia), 30–60 mL PO daily (may take in divided doses). magnesium hydroxide (Milk of Magnesia), Avoid if decreased renal function suspected. 15–40mL PO daily. Avoid if decreased renal function is suspected. May cause cramping. or or lactulose 15–30 mL PO daily lactulose 15–30 mL PO daily. May increase bowel gas May add stimulant laxative for severe constipation that is not responding to osmotic laxatives: May add stimulant laxative for severe constipation that is not responding to osmotic laxatives: sennosides (Senokot), 1–2 tabs once or twice daily until establishment of bowel movements sennosides (Senokot), 1–2 tabs once or twice daily until establishment of bowel movements It is also recommended to suggest a bulk-forming agent (must be taken with adequate fluids): Step 3: If symptoms of difficult defecation, add: psyllium (Metamucil), 1 tsp (5 mL) in 8 oz (250 mL) glycerin suppository, 1 or 2 prn daily fluid PO 1–4 times daily Monitoring and Follow-Up The patient can obtain Metamucil with a prescription through an NIHB pharmacy provider. Follow up regularly every 2–4 weeks until regular bowel function is achieved. Bulk-forming agents Begin bulk-forming agents with a single daily dose, should be maintained in the long term. When and increase frequency of dose every 2–3 days as constipation resolved, step-down therapy to the lowest tolerated. level to maintain regular bowel function. If symptoms of difficult defecation are present, add: sodium (Colace) is a stool softener. It is glycerin suppository, 1 or 2 prn daily better used in situations where straining needs to be avoided for a discrete period rather than as a laxative. or Fleet enema prn over 3–4 days Long-term use of stimulant laxatives (sennosides) and Fleet enemas should be avoided. When fecal impaction is present, manually disimpact as necessary. Use enemas (for example, Fleet, saline, oil retention). Follow up closely until regular bowel function is achieved.

Clinical Practice Guidelines for Nurses in Primary Care 2011 5–8 Gastrointestinal System

Referral Isotonic Dehydration Refer to a physician to arrange further investigation if: –– Combined water and sodium deficit (proportionate loss of water and salt) –– testing of stool for occult blood is positive –– Symptoms less dramatic than in hypotonic –– hemoglobin is low dehydration (use estimated weight loss as a guide: –– there is evidence of other organic disease 5% = mild dehydration, –– this constipation represents a new change in bowel 10% = moderate dehydration, habit in a person > 50 years of age 15% = severe dehydration) –– the constipation is not resolving with appropriate treatment Hypertonic Dehydration Severe straining at stool or a continued sensation of –– Primarily due to a water deficit (more water rectal fullness even when rectum is empty warrants than salt is being lost) a more thorough evaluation. –– May occur as a result of using high solute fluid as replacement, renal concentration with large DEHYDRATION free-water losses (diuretics), large insensible (HYPOVOLEMIA)20,21,22,23,24,25,26 water losses (heat exposure), diabetes insipidus, infections, fever Abnormal decrease in volume of circulating plasma. –– Typical symptoms include thick, doughy texture to skin (tenting is uncommon), tachypnea, intense thirst CAUSES –– Shock is a very late manifestation –– Excessive urine production (for example, use of diuretics, unexplained polyuria or polydipsia) PHYSICAL EXAMINATION –– Excessive gastrointestinal (GI) losses (through –– Assess for orthostatic if supine vomiting, diarrhea, third spacing of fluid in the blood pressure appears normal (take supine blood abdomen as a result of ascites or pancreatitis) pressure after the patient is lying for 5–10 minutes, –– Excessive losses through the skin (because then take the blood pressure as soon as the patient of , fever, exfoliative ) sits up or stands and again in this position after –– Inadequate intake of food or fluids (because 2–3 minutes; a drop in systolic blood pressure of gastrointestinal illness, immobility, loss ≥ 20 mm Hg or a drop in diastolic blood pressure of consciousness, cognitive impairment) ≥ 10 mm Hg from supine indicates orthostatic hypotension27) TYPES –– Assess for orthostatic (afebrile pulse > 100 beats/minute or a pulse change of 10–20 Hypotonic Dehydration beats/minute with position change as described in –– Primarily due to a sodium deficit (more salt than the previous bullet) water is being lost) –– Check weight (acute weight loss can help define –– May result from replacing gastrointestinal losses degree of dehydration) (vomiting and diarrhea) with low-solute fluids such –– Estimate volume deficit – 1 L loss equals about as dilute juice, cola, weak tea 1 kg of weight (see Table 1, “Physical Findings –– Symptomatic earlier than isotonic or hypertonic in Association with Degree of Dehydration”) dehydration (use estimated weight loss as a guide: 3% = mild dehydration, 6% = moderate dehydration, 9% = severe dehydration) –– Lethargy and irritability are common, and vascular collapse can occur early

2011 Clinical Practice Guidelines for Nurses in Primary Care Gastrointestinal System 5–9

Table 1 – Physical Findings in Association with Degree of Dehydration Clinical Sign Mild Dehydration Moderate Dehydration* Severe Dehydration* Fluid loss (% of body weight) < 6 % 6 % to 10 % > 10 % Radial pulse Normal Rapid, weak Very rapid, feeble Respiration Normal Deep Deep, rapid Systolic blood pressure Normal Low or orthostatic >10 mm Very low or undetectable Hg change Skin turgor Retracts rapidly Retracts slowly Retracts very slowly Eyes Normal Sunken Very sunken Mentation Alert Restless Drowsy, comatose Urine output Normal Scant Oliguria Voice Normal Hoarse Inaudible *If dehydration is moderate to severe, there may be associated electrolyte disturbances.

CONSIDERATIONS IN THE ELDERLY General Principles of Rehydration –– Present with nonspecific Fluid therapy involves two components: maintenance (for ongoing fluid losses) and replacement (to correct –– Acute weight loss is the most specific finding water and electrolyte deficits) (Note: elderly have lower total body water relative to weight, therefore there is a greater reduction in –– Be sure to calculate required fluid volume as: extracellular water volume with weight loss) known losses (for example, urine output, emesis) –– There may be other explanations for findings that + maintenance fluids + replacement fluids suggest hypovolemia (for example, dry mouth may –– If client is eating, calculate fluid intake at 75% of total be due to medications, associated –– In hypotonic or isotonic dehydration, calculate total with disuse and atrophy) fluids (maintenance + replacement) for the first –– At higher risk for hypernatremia due to impaired 24 hours, and give half this amount over the first thirst stimulus and limitations to increased fluid 8 hours, and the other half over the next 16 hours intake due to immobility, impaired swallowing –– In hypertonic dehydration, correct the fluid deficits –– Elderly individuals at risk for volume depletion slowly (over about 48 hours) include: –– Do not add potassium to intravenous (IV) line until –– female gender urine output is established (diabetic ketoacidosis –– age > 85 years may be an exception, where correction of –– > 4 chronic conditions hyperglycemia and acidosis may lead to rapid –– > 4 medications development of hypokalemia) –– bedridden The search for the underlying cause of the dehydration –– laxative use should be concurrent with rehydration therapy –– chronic infections to prevent the re-emergence of dehydration from ongoing fluid losses. MANAGEMENT

Goals of Treatment –– Restore normal state of hydration –– Identify and rectify cause of dehydration

Nonpharmacologic Interventions See “Shock” in the chapter “General Emergencies and ”.

Clinical Practice Guidelines for Nurses in Primary Care 2011 5–10 Gastrointestinal System

Rehydration Methods Intravenous Oral –– Normal saline or Ringer’s lactate are the fluids –– is the initial method of choice for rehydration of treatment unless oral intake is unfeasible or the –– Rapid infusion in patients with a history of cardiac volume of the deficit and the resulting severity failure or in the elderly may result in fluid overload of symptoms make IV therapy necessary –– Oral rehydration fluids are effective thus rehydration Maintenance29 should be attempted in clients with adequate blood The requirement for maintenance fluids varies pressure who are able to take fluids orally with the weight of the adult (see Table 2, “Hourly –– Oral rehydration fluids should contain both sodium Maintenance Fluid Requirements in Adults Weighing and sugar to maximize absorption of these two 20–80 kg (1 hour periods)”). Various medical components conditions will also affect these requirements (see Table 3, “Conditions Modifying Daily Maintenance An oral rehydration solution can be made at home Fluid Requirements”). Increase daily maintenance with table salt and sugar: 1 tsp (5 mL) salt, 8 tsp fluids by 100–150 mL/day (40 mL) sugar (any form of raw sugar), 4 cups (1 L) for every degree Celsius body temperature above water. Caution should be used when recommending 37.0°C (oral). Maintenance fluids can be given 28 this as there is potential for major mixing errors. intravenous or by mouth. Commercially prepared solutions are also available (for example, Gastrolyte).

Table 2 – Hourly Maintenance Fluid Requirements in Adults Weighing 20–80 kg (1 hour periods)29 Calculation 4 mL/kg/hour for first 10 kg of body weight + 2 mL/kg/hour for the next 10 kg of body weight (over the initial 10 kg of body weight) + 1 mL/kg/hour for each kilogram over 20 kg of body weight **Maximum of 120 mL/hour or 3000 mL a day needed for maintenance Examples For 20 kg adult: (10 kg x 4 mL/kg/hour) + (5 kg x 2 mL/kg/hour) = 50 mL/hour = 50 mL/hour For 45 kg adult: (10 kg x 4 mL/kg/hour) + (10 kg x 2 mL/kg/hour) + (25 kg x 1 mL/kg/hour) = 85 mL/hour

Table 3 – Conditions Modifying Daily Maintenance Fluid Requirements29 Requirements Increased Requirements Decreased Fever, sweating Renal failure Ongoing significant vomiting or diarrhea Edematous states (for example, heart failure, cirrhosis) Diabetes Hypothyroidism Burns Note: with a fever, daily maintenance fluids should be increased by 100–150 mL/day for every degree Celsius body temperature above 37.0°C (oral)

Replacement29 Association with Degree of Dehydration.” These Therapy is dependent on the amount of fluid lost. indicators are also used to monitor response and need for further fluid therapy. No formula accurately estimates fluid deficit, unless the amount of weight lost is known. Clinical The following guidelines will have to be modified in indicators, like blood pressure, skin turgor, mental states of hypernatremia and hyponatremia to ensure no status and urine output are used to estimate the neurologic damage results. volume lost. Replacement therapy depends on the extent of dehydration. To determine the degree of dehydration see Table 1, “Physical Findings in

2011 Clinical Practice Guidelines for Nurses in Primary Care Gastrointestinal System 5–11

Mild to Moderate Dehydration Referral –– Administer 50–100 mL per hour orally, if possible, Medevac any client who: in addition to any continued losses (for example, –– is moderately dehydrated (6% to 10% weight loss) emesis, urine output, diarrhea) and in addition to if the blood pressure and mental status does not maintenance requirement (see Table 2, “Hourly stabilize in the normal range within 1 hour of Maintenance Fluid Requirements in Adults initiating rehydration therapy Weighing 20–80 kg”) –– is severely dehydrated (≥ 10% weight loss) –– Give fluid frequently and in small amounts –– is elderly and has multiple medical problems –– Fluid intake in the first 24–48 hours should –– is unable to tolerate fluids by mouth be enough to replace the initial deficit plus any ongoing loss of fluid through the GI –– in whom bowel sounds are absent and genitourinary tracts and the skin –– has abdominal tenderness or rebound tenderness –– has high fever and appears acutely ill Severe Dehydration –– Start 2 large-bore IV lines (16- or 18-gauge) DIARRHEA30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45, with normal saline or Ringer’s lactate 46,47,48,49,50,51,52 –– Give normal saline or Ringer’s lactate 20 mL/kg IV rapidly over 15 minutes as a bolus (infuse more Episodes of frequent loose or liquid stool (may be slowly if cardiac failure risk and for older clients) of large or small volume). –– Reassess for signs of continuing hypovolemic –– Acute diarrhea: lasting less than 14 days shock and cardiac and respiratory function –– Persistent diarrhea: lasting more than 14 days –– If shock persists, continue to administer fluid –– Chronic diarrhea: lasting more than 30 days in 500–1000 mL boluses, reassessing with each infusion Diarrhea is a symptom, not a diagnosis. A careful, –– Aim for pulse rate < 100 bpm, systolic blood in-depth, accurate history and physical examination pressure > 90 mm Hg and normal mental status are mandatory to establish the underlying cause. –– Adjust IV rate according to clinical response Acute diarrhea is usually caused by viral, bacterial or (ongoing IV therapy is based on response to parasitic infection and is self-limited. Symptoms that initial fluid resuscitation, continuing losses persist beyond 14 days require further investigation and underlying cause of dehydration) for other causative factors. –– Consult physician as soon as possible after CAUSES rehydration is initiated Potassium Acute Diarrhea53 –– For mild dehydration, potassium may not –– Viral infection (most common cause): norovirus, be required rotavirus; in immunocompromised clients, cytomegalovirus, adenovirus and , –– For moderate-to-severe dehydration caused hepatitis A by GI or renal losses, potassium replacement (for example, potassium chloride) may be required; –– Bacterial infection: Campylobacter, Clostridium consult a physician for an order difficile (recent antibiotics and immunocompromise are risk factors), , E. coli Monitoring and Follow-Up (h5) O157:H7, Salmonella, Shigella, , Yersinia, Clostridium perfringens, Bacillus Monitor hydration, general condition and vital cereus, Vibrio parahaemolyticus signs frequently until stable. Follow up in 24 hours –– Parasitic infection Giardia lamblia, (sooner if oral intake is not keeping up with losses). Cryptosporidia, Microsporidia, Isospora, Cyclospora

Clinical Practice Guidelines for Nurses in Primary Care 2011 5–12 Gastrointestinal System

Persistent or Chronic Diarrhea54 PHYSICAL FINDINGS –– Osmotic diarrhea: magnesium, phosphate or –– Temperature may be elevated (if cause is infectious sulphate ingestion, carbohydrate or inflammatory bowel disease) –– Fatty diarrhea: malabsorption (short bowel –– Heart rate may be increased (if dehydration, syndrome, post-resection), maldigestion syndromes fever or metabolic derangement) (pancreatic exocrine insufficiency) –– Weight loss (if dehydration or chronic) –– Inflammatory diarrhea: inflammatory bowel disease –– Blood pressure low if severely dehydrated (ulcerative colitis, Crohn’s disease, diverticulitis), –– Postural blood pressure drop if moderately , neoplasia dehydrated –– Secretory diarrhea: medications (antibiotics, –– Client appears mildly to severely ill (depending antacids, laxatives), disorder motility (irritable on cause and severity) bowel syndrome, post-vagotomy), vasculitis, –– Mucous membranes may be dry endocrine conditions (hyperthyroidism, diabetes –– Eyes may be sunken with dark circles underneath mellitus), neoplasia, neuroendocrine tumours –– Skin may feel dry, turgor may be poor –– Other: factitious, overflow secondary to constipation –– Jaundice of sclera, skin (hepatitis A) –– Abdomen may be slightly distended with gas During “spring break-up” and in late summer, –– Bowel sounds hyperactive community outbreaks of E. coli diarrhea are common –– Abdomen hyperresonant if excess gas is present if water quality is poor. E. coli and parasites may also be involved if there has been recent travel. –– Abdomen may be mildly tender in all areas is a rare form of clostridial infection that releases –– may be present (depending on causing neurologic symptoms. underlying cause, for example, Crohn’s disease) –– Rectal exam (gentle) for tenderness (proctitis), HISTORY masses, fecal impaction (causing overflow –– Onset, frequency, duration and volume of loose, diarrhea) watery bowel movements –– Perianal area may be inflamed or excoriated –– Presence of blood, pus or , melena, –– Neurologic symptoms of , (fatty, greasy, bulky stool) paresthesia, motor weakness (botulism) –– Abdominal pain (possibly cramping) DIFFERENTIAL DIAGNOSIS –– Association of symptoms to specific food ingestion –– Fecal incontinence (may be confused with diarrhea) –– Viral infection –– Current or recently used medications, supplements, –– Bacterial infection herbs, traditional medicines –– Parasitic infection –– Recent travel –– Diet induced (for example, excess consumption –– Dietary and fluid intake in past 24 hours of alcohol or fruit) –– Recent intake of untreated water –– Medication induced (for example, current or recent use, laxatives, supplements) –– Associated symptoms: (for example, nausea or vomiting, fever, headache, thirst, light-headedness, –– Irritable bowel syndrome joint pain, mouth ulcers) –– Inflammatory bowel disease (Crohn’s colitis, –– Decreased urine output (may be present if diarrhea ulcerative colitis, ischemic colitis) is severe or prolonged) –– Fecal impaction with overflow diarrhea –– History of personal or family bowel disease –– HIV or AIDS (for example, inflammatory bowel disease, –– Malabsorption syndrome (for example, diverticulosis) lactase deficiency) –– Sexual history (may have proctitis, HIV infection) See other “causes” (in “Diarrhea” section). –– Recent hospitalization If the client is passing bloody diarrhea, consider bacterial infection (Shigella, Salmonella, E. coli O157:H7), inflammatory or ischemic bowel disease.

2011 Clinical Practice Guidelines for Nurses in Primary Care Gastrointestinal System 5–13

COMPLICATIONS –– A normal diet should be resumed as soon as –– Dehydration (see “Dehydration (Hypovolemia)”) the patient can tolerate it. The BRAT diet (that is, bananas, rice, applesauce, toast) is no longer –– Malabsorption (wasting, anemia) recommended as it does not provide adequate –– Fissure, protein and caloric intake55 –– –– Client may consider avoiding coffee, alcohol, –– Hemorrhoids most high fibre fruits and vegetables, red meats –– Systemic infection (sepsis) and heavily seasoned foods initially –– Hemolytic-uremic syndrome –– For persistent or chronic diarrhea, a therapeutic trial of a lactose-restricted diet for 2 weeks may DIAGNOSTIC TESTS confirm as a cause –– Test stool for occult blood Client Education –– Test stool for culture and sensitivity, ova and parasites for severe disease, diarrheal symptoms –– Inform client that proper hand-washing prevents for several days, history of inflammatory bowel the spread of infection disease, bloody diarrhea –– Teach client how to prevent recurrent diarrhea –– Stool for C. difficileif recent antibiotic therapy (by boiling drinking water for at least 20 minutes) or hospitalization –– Teach client to recognize symptoms and signs of –– Test for HIV (in chronic diarrhea or if risk dehydration and advise client to return to clinic behaviours present) if they occur –– Blood cultures if suspected sepsis –– If possible, temporarily discontinue any medications associated with diarrhea MANAGEMENT –– Witch-hazel cotton pads (Tucks) may provide relief o the raw perianal area Goals of Treatment Fluid Therapy –– Relieve symptoms Fluid therapy involves two components: maintenance –– Establish normal bowel function (for ongoing fluid losses) and replacement (to correct –– Prevent complications (for example, dehydration) water and electrolyte deficits). –– Avoid complications of antidiarrheal medications (for example, constipation, toxic ) Oral –– Oral rehydration fluid therapy is effective in Appropriate Consultation treating acute diarrheal illness and should be Consult a physician if the client is moderately used for clients with adequate blood pressure or severely dehydrated or has bloody diarrhea. who are able to take fluids orally –– Elderly and debilitated clients in particular are Nonpharmacologic Interventions at risk for dehydration, and early use of oral Dietary Adjustments rehydration fluids is recommended –– Water, juices and soft drinks do not replace –– Client may need to stop solid foods for a brief electrolytes because they are low in sodium. period (6 hours) if stool is frequent and watery Too much of these hypotonic fluids can lead or if vomiting occurs in association with diarrhea to hyponatremia –– A combination of clear broths, oral rehydration –– Oral rehydration fluids should contain sodium, solutions and a modest amount of hypotonic fluids potassium and sugar to maximize absorption (for example water, juices, soft drinks) may be the of these components best strategy for managing acute diarrhea –– An oral rehydration solution can be made at –– There is evidence that a lactose-free general diet home with table salt and sugar: 1 tsp (5 mL) salt, will decrease the duration and severity of diarrhea 8 tsp (40 mL) sugar (any form of raw sugar), (secondary lactose malabsorption is common 4 cups (1 L) water. Caution should be used when following infectious ) recommending this as there is potential for major mixing errors.56 Commercially prepared solutions are also available (for example, Gastrolyte)

Clinical Practice Guidelines for Nurses in Primary Care 2011 5–14 Gastrointestinal System

Maintenance –– Reassess for signs of continuing , and cardiac and respiratory function The requirement for maintenance fluids varies with the weight of the adult (see Table 2, “Hourly –– If shock persists, continue to administer fluid Maintenance Fluid Requirements in Adults Weighing in 500–1000 mL boluses and reassess with each 20–80 kg” under “Dehydration”). Various medical infusion conditions will also affect these requirements (see –– Aim for pulse rate < 100 bpm, systolic blood Table 3, “Conditions Modifying Daily Maintenance pressure > 90 mm Hg and normal mental status Fluid Requirements” under “Dehydration”). Increase –– Adjust IV rate according to clinical response daily maintenance fluids by 12% for every degree (ongoing IV therapy is based on response to Celsius body temperature above 37.5°C (rectal). initial fluid resuscitation, continuing losses Maintenance fluids can be given intravenous or and the underlying cause of dehydration) by mouth. –– Consult physician as soon possible after intravenous rehydration is initiated Replacement29 Therapy is dependent on the amount of fluid lost. Pharmacologic Interventions No formula accurately estimates fluid deficit, Control nausea and vomiting if significant: unless the amount of weight lost is known. Clinical indicators, like blood pressure, skin turgor, mental dimenhydrinate (Gravol), 25–50 mg IM as status and urine output are used to estimate the a single dose, then 50 mg PO q4-6h prn volume lost. Replacement therapy depends on the Antidiarrheals may help to relieve symptoms: extent of dehydration. To determine the degree loperamide hydrochloride (Imodium), 4 mg to start, of dehydration see Table 1, “Physical Findings in then 2 mg after each loose bowel movement to Association with Degree of Dehydration”. These a maximum of 16 mg/day, then 2–4 mg bid indicators are also used to monitor response and need for further fluid therapy. Antispasmotics may help relieve abdominal cramping: The following guidelines will have to be modified hyoscine butylbromide (Buscopan), 20 mg IM/IV, then 10 mg PO 3–4 times daily in states of hypernatremia and hyponatremia to ensure no neurologic damage results. Monitoring and Follow-Up Mild to Moderate Dehydration Monitor hydration, general condition and vital signs Administer 50–100 mL per hour orally, if possible, in frequently until stable. Follow up in 24 hours (sooner addition to any continued losses (for example, emesis, if oral intake is not keeping up with losses). urine output, diarrhea) and in addition to maintenance requirement (see Table 2, “Hourly Maintenance Fluid Referral Requirements in Adults Weighing 20–80 kg” under Refer the stable client with persistent or chronic “Dehydration”) diarrhea to a physician as soon as possible for evaluation. –– Give fluid frequently and in small amounts –– Re-evaluate the client frequently for responses Consider medevac for any client who: to therapy –– is moderately dehydrated (6% to 10% weight loss) –– Fluid intake in the first 24–48 hours should if his or her heart rate and/or blood pressure does be enough to replace the initial deficit plus not stabilize in the normal range within 1 hour any ongoing loss of fluid through the GI and of initiating rehydration therapy genitourinary tracts and the skin –– is severely dehydrated (≥ 10% weight loss) Severe Dehydration –– is elderly and has multiple medical problems –– Start 2 large-bore IV lines (16- or 18-gauge) –– is unable to tolerate fluids by mouth with normal saline or Ringer’s lactate –– in whom bowel sounds are absent –– Give normal saline or Ringer’s lactate 20 mL/kg –– has abdominal tenderness or rebound tenderness IV rapidly over 15 minutes as a bolus (infuse more –– has high fever and appears acutely ill slowly if cardiac failure risk and for older clients)

2011 Clinical Practice Guidelines for Nurses in Primary Care Gastrointestinal System 5–15

DIVERTICULAR DISEASE57,58,59,60,61,62,63,64 PHYSICAL FINDINGS Diverticular disease encompasses diverticulosis –– Fever (see “Diverticulosis”) and the complications –– Tachycardia of diverticular hemorrhage, diverticulitis (see –– Abdominal tenderness to palpation with possible “Diverticulitis”) and the associated secondary rebound tenderness complications of perforation, abscess, fistula –– Palpable mass may be present, representing and obstruction. an abscess or inflammatory phlegmon –– Bowel sounds may be active if there is partial (PL. DIVERTICULA) obstruction, or hypoactive or absent if The most common colonic diverticula are has developed pseudodiverticula, which are herniations of the –– Rectal exam may help to localize the abscess mucosa and submucosa through the muscularis at or inflammatory mass the sites of penetration of nutrient . Most occur in the sigmoid and descending colon. DIFFERENTIAL DIAGNOSIS Diverticular Bleeding –– Appendicitis –– Inflammatory bowel disease Hemorrhage results from progressive injury and –– Ischemic colitis weakness of the supplying the segment of bowel that has herniated, predisposing the artery to –– Colon cancer rupture and bleeding into the lumen (see “Lower –– Other causes of bowel obstruction Gastrointestinal Bleeding” in the section –– Urologic or gynecologic disorders “Emergencies of the Gastrointestinal System”). COMPLICATIONS DIVERTICULITIS –– Abscess –– Perforation and infection in one or more diverticula. –– Fistula into bladder, vagina or abdominal Often involves the sigmoid colon. wall Peritonitis Micro or macroperforation of the diverticular wall due –– Sepsis to increased pressure from insipissated food particles or increased intraluminal pressure. Small perforations DIAGNOSTIC TESTS are frequently mild and resolve spontaneously, –– Test stool for occult blood however if not well contained, a localized abscess –– Perform urinalysis may form. Complications of fistula formation with adjacent tissues, obstruction, larger perforation and MANAGEMENT peritonitis may develop. Goals of Treatment HISTORY –– Rest the bowel –– Abdominal pain (left lower quadrant most –– Relieve symptoms common) may present acutely, but more often –– Prevent complications develops over hours to days –– Fever and chills Appropriate Consultation –– Anorexia Consult a physician. –– Nausea and vomiting –– Dysuria if inflammation adjacent to bladder Nonpharmacologic Interventions –– Nothing by mouth

Clinical Practice Guidelines for Nurses in Primary Care 2011 5–16 Gastrointestinal System

Adjuvant Therapy PHYSICAL FINDINGS –– Start IV therapy with normal saline to maintain –– May have no findings of significance hydration in client with moderate to severe –– Tenderness may be present symptoms –– Firm, feces-filled sigmoid colon in the left lower –– Insert nasogastric tube if upon consultation abdomen (suggests constipation) a physician supports its use –– Rectal exam may reveal firm, guaiac-negative stool

Pharmacologic Interventions DIFFERENTIAL DIAGNOSIS –– Broad-spectrum antibiotics such as ciprofloxacin –– Irritable bowel syndrome with metronidazole are used; consult a physician –– Diverticulitis before starting IV antibiotics –– Colon cancer –– Antibiotics should be continued for 7–10 days –– Inflammatory bowel disease Referral –– Urologic or gynecologic disorder Medevac. Surgery may be required if there is DIAGNOSTIC TESTS peritonitis, with or without evidence of perforation, unresolved obstruction or development of a fistula. –– Tests may not be indicated if symptoms are Other indications for surgical intervention are failure mild and the client is otherwise healthy to improve after several days of medical treatment –– If symptoms are more severe or if the client and recurrence after successful treatment. has occult , weight loss or other symptoms of concern, a complete blood count should be obtained DIVERTICULOSIS –– Consult a physician about sigmoidoscopy, Presence of multiple diverticula. Does not imply barium enema or a pathologic condition. MANAGEMENT HISTORY –– Similar to irritable bowel syndrome (IBS) –– Risk factors: –– Recommend high-fibre diet –– low intake of dietary fibre –– Recommend avoidance of cathartic laxatives –– age (prevalence of 5% at age 40, 30% by age 60) Nonpharmacologic Interventions –– lack of exercise –– Recommend dietary modifications (for example, –– Most people with colonic diverticula are regular meals, gradual increase of fibre) asymptomatic (70%) –– Recommend increase in fibre content of diet –– If symptomatic, clients may describe: (for example, raw bran, brown bread, popcorn, –– cramping (usually in left lower abdomen) All Bran, Puffed Wheat or Shredded Wheat cereal); when raw (miller’s) bran is used, start with a small –– bloating amount and increase gradually to ¼ to ½ cup daily –– flatulence to avoid bloating and flatulence –– irregular defecation (constipation, diarrhea) –– Recommend avoidance of foods that are known to –– May be difficult to differentiate symptoms from cause symptoms (these vary from person to person) those of irritable bowel syndrome –– Recommend that client consume an adequate –– Earlier onset of diverticular disease is found amount of fluid when using bulking agents in those with connective tissue disorders (for –– Recommend elimination of nicotine and - example, Marfan’s syndrome) and in polycystic containing drugs kidney disease –– Often found as an incidental finding during other investigations

2011 Clinical Practice Guidelines for Nurses in Primary Care Gastrointestinal System 5–17

Pharmacologic Interventions ALARM SYMPTOMS AND SIGNS65,66 Suggest a stool-bulking agent: These symptoms are all indications for which a prompt diagnostic endoscopy is appropriate: psyllium (Metamucil), 1–2 tsp (5–10 mL) orally two or three times daily with 8 oz (250 mL) fluid –– Any persistent dyspepsia in patient aged over The patient can obtain Metamucil with a prescription 55 years with recent (less than 1 year) onset of through an NIHB pharmacy provider. dyspepsia of at least 4 weeks’ duration –– Unexplained weight loss (more than 3 kg or Monitoring and Follow-Up > 10 % body weight) –– Follow up in 1–2 weeks –– Unexplained iron deficiency anemia –– Adjust the dose of fibre depending on response –– Gastrointestinal bleeding –– Use less fibre temporarily if gas and bloating –– Progressive dysphagia and are prominent –– Previous gastric surgery –– Use more fibre if there has been little clinical –– Persistent vomiting response –– Epigastric mass –– Previous esophagogastric malignancy Referral –– Suspicious barium meal Refer to a physician if concerned that symptoms –– Previous peptic ulcer or signs are caused by something other than organic –– Epigastric pain severe enough to hospitalize patient bowel disease or if symptoms do not improve with –– Early satiety management. –– Family history of gastrointestinal cancer –– Lymphadenopathy DYSPEPSIA CAUSES Dyspepsia describes a variety of symptoms from the upper . The most common The most common disorders that may cause dyspepsia patterns of dyspepsia include: symptoms include: Reflux-like dyspepsia symptoms include: –– Gastroesophageal reflux –– Peptic ulcer disease –– –– Biliary pain –– regurgitation of contents –– Alcohol/drug induced /gastropathy –– retrosternal burning –– Diabetic gastroenteropathy Ulcer-like or acid dyspepsia characterized –– Irritable bowel syndrome by symptoms of: There may be significant overlap of symptoms, –– burning sensation in the epigastric area thus determining the cause of dyspepsia without –– hunger-like pain with food investigation can be difficult. Nonetheless, a thorough –– relief with antacid and/or antisecretory medications history will aid in identifying the possible cause and taking appropriate action (see “Dyspepsia called functional dyspepsia which is Algorithm”). defined under the Rome III criteria as: –– a sensation of fullness after eating that causes discomfort (postprandial distress syndrome) –– the inability to eat a normal meal (early satiation) –– epigastric burning or pain (epigastric pain syndrome – occurs between the lower end of the sternum to umbilicus)

Clinical Practice Guidelines for Nurses in Primary Care 2011 5–18 Gastrointestinal System

DYSPEPSIA ALGORITHM

Dyspeptic Symptoms

Refer to Appropriate Suspect GI Cause? No Practice Guideline

Alarm Symptoms? Yes Yes Consult Physician (see “Alarm symptoms”)

No GERD-like Symptoms? (see “GERD”)

Yes No

Refer to GERD Refer to PUD Practice Guideline Practice Guideline (see “GERD”) (see “Peptic Ulcer Disease”)

GALLBLADDER DISEASE61,67,68,69,70,71,72, Cholangitis develops when biliary duct obstruction 73,74,75,76,77 creates bile stasis, providing a medium so that bacteria can track up from the . The high pressure Gallbladder disease includes asymptomatic , in the blocked duct promotes migration of the bacteria biliary colic, cholecystitis, choledocholithiasis into the blood stream causing a systemic infection. and cholangitis. Previous cholecystectomy or absence of gallstones CAUSES does not rule out biliary colic as stones may form within the bile ducts giving rise to similar symptoms. Cholelithiasis is the presence of gallstones within the gall bladder. Most gallstones (60% to 80%) are RISK FACTORS asymptomatic. Small stones are more likely to be symptomatic than large ones. –– Cholelithiasis is more common in women (though men have a higher rate of cholecystitis) Biliary colic usually results from the gallbladder –– Increasing age (adolescents and young adults contracting and pressing a stone against the have the same risk factors and can develop gallbladder outlet or cystic duct opening causing gallbladder disease) increased intragallbladder pressure and pain. Over –– Family history of gallstones time, the gallbladder relaxes and the stone drops back, –– Obesity resolving the symptoms. Multiple episodes of biliary colic, particularly in relation to large or heavy meals –– Pregnancy (unknown if women who are pregnant are common. Similar symptoms may occur from or have multiple pregnancies are more likely microlithiasis or thick bile called biliary sludge. to have gallstones or if they simply have more symptoms of the stones) Choledocholithiasis occurs when the stones become –– Medications that contribute to cholelithiasis lodged in the common ; from this, cholangitis, include estrogen and oral contraceptives, clofibrate, or may occur. ceftriaxone and octreotide Cholecystitis is inflammation of the gallbladder –– Conditions that promote gallbladder stasis caused by obstruction of the cystic duct, usually by a (diabetes mellitus, total parenteral nutrition, (calculous cholecystitis). The inflammation vagotomy, somatostatinoma, spinal cord injury, may be sterile or bacterial. The obstruction may be cirrhosis, hemolytic , hypertriglyceridemia, acalculous (usually in the critically ill) or caused terminal ileal resection) by sludge.

2011 Clinical Practice Guidelines for Nurses in Primary Care Gastrointestinal System 5–19

–– Reduced activity (men) Cholecystitis –– Rapid weight loss (illness, very low calorie diet, –– Present with symptoms of biliary colic that persists surgical therapy for morbid obesity) beyond 6 hours and may have been present for days Considerations in the Elderly –– Pain may be more severe than in previous episodes of biliary colic –– Have a higher rate of cholelithiasis due to increased age –– Nausea, vomiting and anorexia are more common –– May have asymptomatic gallstones with cholecystitis –– More likely to have serious complications, –– Low-grade fever particularly in the absence of biliary colic symptoms –– Elevated white blood cell count (may also be normal) HISTORY –– Jaundice (< 20% of patients)

Onset of symptoms is usually sudden and constant. The Cholangitis client may describe symptoms in association with fatty meals or nighttime onset of pain. They may also describe –– Fever similar episodes in the past. The client may be aware –– Jaundice that they have gallstones. Indigestion, belching, bloating –– Severe right upper quadrant pain and intolerance of fatty food are thought to be typical –– Hypotension and confusion if the illness has symptoms of gallstones; however, these symptoms are progressed to systemic infection just as common in people without gallstones. PHYSICAL FINDINGS Most patients experience symptoms before complications occur, the exception being the elderly –– Vitals signs parallel the degree of illness who may present with acute complications in the –– Clients with biliary colic have relatively normal absence of biliary colic symptoms. Clients presenting vital signs with unremitting pain beyond 6 hours or fever are –– Tachycardia and fever present with cholangitis, at risk for complications of cholecystitis. A thorough may also be present with cholecystitis history with an in-depth symptom inquiry and careful –– Hypotension may present in clients with physical examination is important to identifying cholangitis clients at risk for complications. –– Voluntary/involuntary guarding –– Fever may be absent, especially in elderly clients Biliary Colic –– Jaundice (due to choledocholithiasis, cholecystitis, –– 1–6 hours of constant epigastric and/or right upper cholangitis) quadrant pain that is often described as dull, boring or pressure-like ABDOMINAL EXAMINATION IN –– Usually, intensity varies from mild at onset GALLBLADDER COLIC AND CHOLECYSTITIS building to a the maximum intensity within the –– Epigastric or right upper quadrant tenderness first hour, then resolves within 6 hours –– Murphy’s sign (an inspiratory pause on palpation –– Pain may radiate to the right scapular region or back of the right upper quadrant; specific but not –– Onset of pain often occurs hours after a meal sensitive for gallbladder disease) –– Night onset of pain is common and may wake –– Guarding on palpation the client from sleep –– Peritoneal signs of rebound tenderness in the right –– Pain is unchanged by movement, though the client upper quadrant (with cholecystitis, cholangitis) may change position frequently in search of relief –– Palpable gallbladder or fullness in the right upper –– Antacids, flatus and bowel movements do not quadrant may be palpated provide relieve As in anyone with abdominal pain, a complete physical –– Associated symptoms include nausea, vomiting, examination must be performed (including rectal and diaphoresis, pleuritic pain (Note: unremitting, pelvic examinations in women). In elderly and diabetic severe epigastric pain with vomiting may indicate clients, occult cholecystitis or cholangitis may be the an acute pancreatitis from a gallstone obstructing source of fever, sepsis or changes in mental status. the pancreatic duct) –– NSAIDs or opioid analgesics may provide some relief

Clinical Practice Guidelines for Nurses in Primary Care 2011 5–20 Gastrointestinal System

DIFFERENTIAL DIAGNOSIS DIAGNOSTIC TESTS –– Appendicitis The choice of laboratory tests will depend on whether –– Acute bowel obstruction the client is well enough to be treated as an outpatient –– Ascending cholangitis or requires a more in-depth laboratory investigation –– Cholelithiasis in the hospital. The results of lab tests should be completely normal if the client has cholelithiasis or –– Esophageal conditions (esophageal spasm, gallbladder colic. Elevation of liver function tests ) indicates complications within the biliary system. –– Diverticular disease –– Gastroenteritis –– Complete blood count with differential and –– Gastritis liver function tests (LFTs) levels (alanine aminotranferease [ALT] aspartate aminotranferease –– Hepatitis [AST], bilirubin and alkaline phosphate [ALP]) –– Inflammatory bowel disease may be helpful in the diagnosis of cholecystitis –– Mesenteric ischemia and cholangitis –– Pancreatitis –– Choledocholithiasis may cause elevation of ALP –– Peptic ulcer disease and a significant rise in the AST and ALT –– Viscus perforation –– An elevated bilirubin > 3.5 μmol/L and elevated –– Abdominal abscess alkaline phosphatase may indicate a stone in the –– Aortic aneurysm or ascending cholangitis –– Cardiac disease (myocardial ischemia, myocardial –– Cholecystitis may cause elevation of the WBC infarction, angina, pericarditis) and mild rise in the ALP, AST and ALT, though –– Right sided pneumonia there may be no appreciable change –– Complications of pregnancy (eclampsia, ruptured –– Mild elevation of amylase (to up to 3 times normal ectopic pregnancy, hyperemesis gravidarum) level) may be present in cholecystitis, especially –– Right kidney disease (calculus, pyelonephritis, if there is gangrene polycystic disease, tumour) –– Cholangitis causes a rise in the WBC with an increase in bands on the differential, as well as COMPLICATIONS elevation of liver function tests –– Cholelithiasis (stones descending into the biliary –– Elevated lipase is indicative of pancreatitis and pancreatic ducts) –– In febrile clients, blood cultures should be drawn –– Cholecystitis prior to antibiotic therapy if possible –– Pancreatitis (due to gallstone blocking –– Urinalysis pancreatic duct) –– Pregnancy test for women of childbearing age –– Cholecystofistula (fistula between perforated –– Abdominal ultrasound, upon consultation a gallbladder and duodenum or ) physician –– Gallstone (due to gallstone obstruction MANAGEMENT of a cholecystofistula) –– Gallbladder perforation Uncomplicated presentations of biliary colic may be –– Gangrenous gallbladder managed without medical evacuation. Research has demonstrated that nonsteroidal anti-inflammatory –– Emphysematous cholecystitis (due to infection (NSAID) medication is equivalent to narcotics from gas-producing organisms) for pain management. Patients who have received –– Peritonitis NSAIDs also have a lower likelihood of progressing –– Cholangitis to cholecystitis78 –– Septic shock –– Abscess Appropriate Consultation Clients with pain that does not resolve within 6 hours require consultation and further medical evaluation for complications of gallbladder disease or other underlying medical conditions. Severe pain unresponsive to usual therapy, fever, hypotension

2011 Clinical Practice Guidelines for Nurses in Primary Care Gastrointestinal System 5–21 or peritoneal signs are also indicators for consultation. Referral Clients presenting with severe unremitting, gnawing The risk of complications from gallstones within constant right upper quadrant/epigastric pain with/ 2 years of the first incident of biliary colic is about without radiation to the back and nausea and 70%. Refer the client as soon as possible to a vomiting may have pancreatitis (see “Pancreatitis” physician for abdominal ultrasound if there is no in the section “Emergencies of the Gastrointestinal history of gallstones or if there is new onset of biliary System”). colic with known asymptomatic gallstones.

BILIARY COLIC CHOLECYSTITIS OR CHOLANGITIS

Goals of Treatment Goals of Treatment –– Relieve pain, nausea and vomiting –– Relieve pain, nausea and vomiting –– Prevent complications –– Prevent complications

Appropriate Consultation Appropriate Consultation Consult physician if pain does not resolve within Suspected cholecystitis or cholangitis requires 6 hours, if fever develops or if significant vomiting consultation with a physician and possible medical continues, as these symptoms indicate that a evacuation. complication may be developing. Adjuvant Therapy Nonpharmacologic Interventions –– IV therapy with normal saline, rate adjusted –– according to age, state of hydration and pre- –– Clear fluids if vomiting existing medical problems Client Education –– Oxygen, if client is unstable on presentation –– Explain disease process and prognosis –– Two large-bore IV lines and administration of IV fluids to unstable clients –– Counsel client about appropriate use of medications (dose, frequency) –– Draw aerobic and non-aerobic blood cultures for febrile clients (prior to administering antibiotics) –– Recommend low- food as tolerated, once pain resolves –– Insert nasogastric tube if upon consultation a physician supports its use. Attach to straight Pharmacologic Interventions drainage

Analgesia Nonpharmacologic Interventions ketorolac 30 mg IM q6h as needed (maximum –– Bed rest 120 mg/24 hours). Not for use in those with an –– Nothing by mouth active peptic ulcer or recent GI bleed. If not responding, renal impairment or allergy/ Pharmacologic Interventions intolerance: Analgesia morphine 5–10 mg IM or SC q3–4h as needed Several recent studies have shown that early pain Antiemetics to relieve nausea and vomiting: control in patients with abdominal pain does not dimenhydrinate (Gravol), 25–50 mg IM q4–6h hinder the diagnosis. Therefore, pain control should as needed be given early, without waiting for the diagnosis or surgical consult.79 Monitoring and Follow-Up ketorolac 30 mg IM q6h as needed Monitor for a few hours. When nausea and vomiting (maximum 120 mg/24 hours) have resolved, push clear fluids. Follow-up in If not responding, renal impairment or allergy/ 24 hours is recommended. Clients without renal or intolerance: gastrointestinal risk may use 400 mg orally at the onset of pain with future attacks. morphine 5–10 mg IM or SC q3–4h as needed

Clinical Practice Guidelines for Nurses in Primary Care (Revised April 2013) 2011 5–22 Gastrointestinal System

Antiemetics to relieve nausea and vomiting: –– Defective esophageal clearance dimenhydrinate (Gravol), 25–50 mg IM q4–6h –– Hypersecretion of gastric acid as needed –– High-fat diet Antibiotics –– Concomitant hiatus hernia and diabetes –– Delayed gastric emptying For uncomplicated cholecystitis, where inflammation is the primary process, prophylactic antibiotics are HISTORY usually given to prevent secondary bacterial infection –– Heartburn, most often after eating from bile stasis although evidence of benefit is lacking. If the client is febrile, antibiotic therapy with –– Retrosternal burning sensation radiating upward more broad-spectrum coverage is usually initiated. (may radiate as far up as the throat) –– Acidic stomach contents may be regurgitated Prophylactic therapy: –– Disturbed sleep from symptoms cefazolin 1 g IV every 8 hours –– Dry cough at night or –– Associated symptoms may include: ampicillin 2 g IV every 6 hours –– cough, sore throat, hoarseness, wheezing and –– difficulty swallowing (from erosive esophagitis metronidazole (Flagyl), 500 mg IV q12h or narrowing of esophagus) –– painful swallowing (from esophageal ulcer) Monitoring and Follow-Up –– nausea Monitor pulse oximetry, vital signs (frequent), blood –– hypersalivation (water brash) glucose, intake and output. –– night cough, night awakenings due to pain Severe cholecystitis can evolve into sepsis, cholangitis –– globus sensation (feeling of something stuck or death, especially in diabetic or elderly clients in in throat) whom the diagnosis may be delayed. –– Aggravating factors may include: –– large meals, lying down and bending over Referral –– certain foods (common irritants include caffeine, Medevac as soon as possible; surgical consult chocolate, alcohol, peppermint, fatty foods) is required. –– tight-fitting clothes –– increased perception of symptoms with stress GASTROESOPHAGEAL REFLUX –– Alleviating factors may include: DISEASE (GERD)80,81,82,83,84,85,86,87,88,89,90,91 –– relief with antacids, gum chewing –– sitting up, lifting head of bed Reflux of gastric contents into the esophagus, which –– avoidance of certain foods or beverages to limit results in esophageal irritation or inflammation. symptoms CAUSES Clients who complain about heartburn and/or regurgitation at least twice weekly are considered to Presence of acidic stomach contents in the esophagus have gastroesophageal reflux disease (GERD) unless due to laxity of the lower esophageal sphincter. they have additional symptoms or a trial of therapy Predisposing Factors for ERD has failed. –– Obesity PHYSICAL FINDINGS –– Pregnancy Assess weight. Mild epigastric tenderness may –– Estrogen therapy be present. –– Medications (for example, nitrates, anticholinergics, calcium channel blockers) DIFFERENTIAL DIAGNOSIS –– Tobacco use –– Peptic ulcer disease –– Alcohol use –– Esophageal motility disorder –– Genetic factors

2011 Clinical Practice Guidelines for Nurses in Primary Care Gastrointestinal System 5–23

–– GI bleeding Appropriate Consultation –– Esophageal tumour Consult a physician if the following alarm symptoms –– Esophagitis (pill esophagitis, infectious are detected: esophagitis, ) –– Weight loss due to severity or duration –– Anginal/cardiac pain of symptoms –– Medication-induced epigastric pain –– Difficult or painful swallowing –– Biliary pain –– Sticking of solids or liquids in esophagus area –– Pancreatitis –– Persistent vomiting –– Gastritis –– Pain radiating to back, neck, jaw, left arm COMPLICATIONS or shoulder –– Anemia –– Barrett’s esophagus (pre-malignant mucosal –– Active gastrointestinal bleeding (black stools, changes due to chronic GERD, most common hematemasis) (see “Gastrointestinal Bleeding over age 50) (Upper and Lower)” in the section “Emergencies –– Esophagitis/esophageal ulcer of the Gastrointestinal System”) –– –– Stool positive for occult blood –– Nocturnal aspiration (, cough, asthma, recurrent pneumonitis) Nonpharmacologic Interventions –– Posterior laryngitis, chronic hoarseness –– Elevate the head of the bed 15 cm (6 in) using –– Dental erosions wooden blocks –– Chronic sinusitis –– Encourage weight loss (if weight > 20% of ideal –– Pharyngitis body weight for age and sex) –– Subglottic –– Eliminate (when possible) drugs that impair –– Laryngeal/esophageal cancer esophageal motility and lower esophageal sphincter tone (for example, calcium channel blockers, beta- DIAGNOSTIC TESTS blockers, tricyclic antidepressants, anticholinergics, –– Test stool for occult blood theophyllines) –– Measure hemoglobin level Client Education –– Test for H. pylori (by serology or breath test, –– Counsel client about appropriate use of which must be ordered by a physician) medications (dose, frequency) MANAGEMENT –– Recommend: –– dietary modifications (decrease or eliminate The severity of GERD cannot be determined by coffee, tea, chocolate, nicotine, alcohol and symptom presentation, though dysphagia may indicate fatty foods) erosive esophagitis or esophageal ulceration due –– smoking cessation (decreases salivation) to reflux. Any symptoms of dysphagia need urgent –– small, frequent meals to prevent over-distention consultation and investigation. of the stomach Goals of Treatment –– avoidance of eating large meals/snacks 2–3 hours before bedtime –– Relieve symptoms, especially heartburn –– postural modifications (daytime and nocturnal) –– Promote healing of the esophagus to prevent acid from entering the esophagus –– Prevent complications such as stricture, bleeding, (elevate head of bed 15 cm [6 in] using blocks) Barrett’s esophagus –– client avoid bending at the waist (especially –– Prevent recurrence after meals), as well as lying down immediately after a meal –– avoidance of tight-fitting clothing

Clinical Practice Guidelines for Nurses in Primary Care 2011 5–24 Gastrointestinal System

Pharmacologic Interventions HEMORRHOIDS92,93,94,95,96,97 Clients with frequent symptoms (> 3 days per Blood vessels beneath the anal canal mucosa (internal) week) would benefit from acid repression therapy and perianal skin (external) that have become engorged. (H2-receptor antagonist [H2RA] or proton pump inhibitors [PPI]) to provide more effective relief CAUSES of symptoms than antacids. Proton pump inhibitors such as Losec are used to treat moderate to severe or –– Advancing age (most common ages 45–65) refractory GERD. They are more effective for healing –– Late pregnancy esophageal ulceration and maintaining remission –– Chronic straining at bowel movements of symptoms from GERD. –– Constipation (may be drug related), repeated passage of hard stool If symptoms occur less than 3 times per week: –– Prostatic enlargement with chronic straining Antacids as needed to control symptoms: to urinate aluminum hydroxide/magnesium hydroxide (Maalox, –– Prolonged sitting Alumag), 30 mL orally after meals and before bed, increase as needed HISTORY or Assess for symptoms suggestive of other underlying bowel pathology H2-receptor antagonists: ranitidine (Zantac), 150 mg orally twice daily External Hemorrhoid In elderly clients and those with reduced renal –– Tendency to thrombose function, the doses should be one-half to one-quarter –– Soft skin tags may be present (indicates the usual doses. previous thrombosed hemorrhoids) If symptoms occur 3 or more times per week, or if –– Discomfort or irritation frequently present no response to antacids and lifestyle modification –– Painful if thrombosed within 4 weeks, in consultation with the physician –– Palpable perianal lump or nurse practitioner consider proton pump inhibitor therapy (PPI). Internal Hemorrhoid rabeprazole sodium (Pariet), 20 mg orally daily –– Bright red bleeding with bowel movements for 4 weeks –– Blood on stool surface only, not mixed in with stool; often seen on toilet tissue Monitoring and Follow-Up –– Pain, pressure, mucus production with prolapsed Monitor every 4 weeks. Continue therapy to which hemorrhoids (may feel pressure or tissue client is responding for 8–12 weeks. Reassess “sticking out of rectum”) for symptom relapse in 4–8 weeks when therapy –– May indicate inability to push hemorrhoid complete. If symptoms recur, resume previous back inside therapeutic regimen and refer client to physician. –– Prolapsed hemorrhoids may strangulate or incarcerate Referral Internal hemorrhoids may be graded by history: Refer to a physician any client with: Grade I – bleeding without prolapse –– refractory symptoms not controlled with initial Grade II – prolapse with spontaneous reduction therapy after 8–12 weeks Grade III – prolapse with manual reduction –– atypical chest pain Grade IV – incarcerated, irreducible prolapse –– chronic reflux and over 55 years of age Grade I and II hemorrhoids are often successfully –– symptoms suggesting complications of GERD: treated with conservative medical treatment. Grade III –– cough, sore throat, hoarseness, wheezing and Grade IV hemorrhoids may require surgery. –– night cough, night awakenings due to pain

2011 Clinical Practice Guidelines for Nurses in Primary Care Gastrointestinal System 5–25

PHYSICAL FINDINGS MANAGEMENT

To examine anal area, have client lie on left side with Goals of Treatment the knees drawn up to the chest; retract the buttocks. –– Relieve symptoms –– Both internal and external hemorrhoids may –– Keep anal region clean be present –– Promote easy passage of stool on a regular basis –– Usually located in left lateral, right anterior and right posterior positions Appropriate Consultation –– Internal hemorrhoids covered by thin, pink Contact a physician as soon as possible if unable to anal mucosa are not readily palpable (internal reduce a prolapsed internal hemorrhoid, or if there palpable masses/lumps need referral for further is an acutely thrombosed, bleeding or ulcerated investigation) hemorrhoid. –– External hemorrhoids covered by skin (Note: a thrombosed external hemorrhoid is a bluish purple, Nonpharmacologic Interventions globular, irreducible, tender lump at the edge of the anus) –– Gently try to reduce painful prolapsed internal –– Typically 1 to 3 swellings around anal opening, the hemorrhoid. Apply a topical anesthetic (for size of a finger tip; pink, purple or blue in colour example, lidocaine [Xylocaine] jelly 2%), wait 15 minutes, then gently try to reduce it. Do not –– Rectal examination may reveal concealed internal use force! hemorrhoids –– Warm sitz baths 3 or 4 times daily for 15–20 –– Assess whether prolapsing hemorrhoids are easily minutes followed by gentle drying of the skin to reducible cleanse the area, soothe local irritation and relax –– Anal fissure may also be present (found in 20% of the anal sphincter patients with hemorrhoids) Client Education DIFFERENTIAL DIAGNOSIS –– Instruct client to gently reduce (push back up) –– Rectal or prolapse painless prolapsed internal hemorrhoid(s) –– Skin tag(s) –– Instruct client to cleanse the perianal area after –– Anal warts each bowel movement with plain water, salt water –– Other causes of and perianal dermatitis or medicated witch-hazel cotton pads (Tucks), –– Perianal or perirectal abscess and dry area well –– Anal fissure –– Counsel client about appropriate use of medications (dose, frequency, dangers of overuse) –– Complicated hemorrhoid (thrombosed, prolapsed, incarcerated) –– Teach client proper perianal hygiene and to avoid sitting on toilet for prolonged periods –– Crohn’s disease –– Instruct client to return to clinic for reassessment if –– Tumour of the rectum or sigmoid colon severe pain or bleeding develops (incision drainage COMPLICATIONS of thrombosed external hemorrhoid may be required) –– Instruct client to apply an ice pack (20 minutes on, –– Thrombosed or strangulated internal hemorrhoid 20 minutes off) to help reduce swelling and pain –– Thrombosed external hemorrhoid if a thrombosed hemorrhoid is suspected –– Bleeding (may drip, bleed briskly or squirt) –– Advise client to increase dietary fibre and fluids –– Ulceration of overlying skin –– Stool incontinence

DIAGNOSTIC TESTS –– Stool may test positive for occult blood

Clinical Practice Guidelines for Nurses in Primary Care 2011 5–26 Gastrointestinal System

Pharmacologic Interventions –– Increased intra-abdominal pressure (obesity, Relief of Local Pain/Irritation pregnancy, ascites, peritoneal dialysis) –– Age For mildly sore and edematous “inflamed” external –– Heavy lifting hemorrhoid, treat with hemorrhoidal ointments or –– Chronic cough suppositories without corticosteroids (ointments are better): –– Chronic straining to pass stool or to urinate –– Congenital defect of abdominal wall zinc sulfate 0.5% ointment or suppository (for example, Anusol) every morning and evening HISTORY and»after each bowel movement for 3–7 days For perianal dermatitis, hemorrhoidal ointment with Groin Hernia corticosteroids (for anti-inflammatory properties) –– Presence of predisposing factor may be used to reduce and discharge: –– May be asymptomatic or cause sense of heaviness zinc sulfate 0.5% with hydrocortisone 0.5% ointment or dull discomfort (for example, Anusol HC) –– Sensation may be increased with abdominal Note: Topical corticosteroids should not be used for straining, long periods of standing or at the end more than 7 days as they may have deleterious effects of the day when physically active on tissues. –– Soft, non-tender bulge that may appear when standing, straining or during times of increased Promote Ease of Stool Passage intrabdominal pressure (bowel movements, bulking agents and stool softeners (see cough, sneeze) “Pharmacologic Interventions” in the section –– Bulge disappears when lying down unless “Constipation”) incarcerated –– Pain indicates development of complications Monitoring and Follow-Up Follow up in 1 week to determine if symptoms Abdominal Hernia have improved. –– Presence of predisposing factor –– Bulge through abdominal wall at umbilicus, Referral epigastrum or an incision site For acute pain of recent onset (1–2 days) that is –– May cause discomfort that is worse with straining increasing despite treatment, contact a physician –– Pain indicates development of complications for advice and to rule out an abscess. –– Men present with incarceration of umbilical hernias more commonly than women HERNIA75,76,77,78,79 PHYSICAL FINDINGS Protrusion of part of the abdominal contents (bowel, omentum) through a weakness in the abdominal wall. Groin Hernia Hernias may occur through physiologic openings Examine the client in the standing position to help (inguinal, femoral) or at weak points of the abdominal identify swelling. Have the client cough, strain or muscles (ventral hernias – umbilicus, between perform a Valsalva maneuver. muscles, incision sites). –– Bulge may be seen in groin, may extend into CAUSES scrotum –– Defect of abdominal wall muscles –– Bulge may be seen on upper anterior thigh () or abdomen Predisposing Factors –– Hernia disappears upon lying down, reappears –– Abdominal surgery ( – increased upon standing up or bearing down risk if had post-operative wound infection, obese, –– Hernia may be palpable across the inguinal/ a smoker, immunocompromised, undernourished, femoral/inguinal region during straining have connective tissue disorder or the surgical technique was poor)

2011 Clinical Practice Guidelines for Nurses in Primary Care Gastrointestinal System 5–27

–– In men, a hernia may be felt by invaginating COMPLICATIONS the scrotal skin, gently extending the finger into –– Strangulated hernia the inguinal canal along the spermatic cord and –– Incarcerated hernia asking the client to cough/strain – additional pressure on the side or tip of the finger aside from –– Ischemic bowel (due to strangulation or the circumferential pressure of the external ring incarceration) may be a hernia –– Bowel obstruction –– Hernias should be gently reduced by gently DIAGNOSTIC TESTS pressing the contents back into the abdominal cavity –– None –– Tender/painful hernias or those associated with MANAGEMENT nausea/vomiting should not be reduced –– A painful or non-reducible inguinal mass should Goals of Treatment be considered a strangulated hernia until it is proven otherwise –– Reduction of the hernia –– Support weak abdominal wall Abdominal Hernia –– Relieve discomfort –– Bulge in abdominal wall –– Prevent recurrence and further enlargement –– May be tender with palpation Appropriate Consultation –– Weakness in abdominal wall is palpable with incisional hernias, (palpate the entire length Consult a physician immediately if the hernia is not as there may be more than one defect) reducible, if it is painful, or if it is associated with –– Bulge at umbilicus (may appear asymmetric) symptoms and signs of bowel obstruction. Consult a physician immediately if a painless femoral hernia –– Epigastric hernias are located along the midline is suspected. between the xiphoid process and umbilicus and usually present as a small lump (usually < 1 cm Nonpharmacologic Interventions in diameter); incarceration is common –– Discomfort may increase when lying down with With client lying down, attempt to reduce the inguinal epigastric hernias or incisional hernia with gentle manual reduction. –– A bulge in the abdominal wall along the midline –– Do not use force that appears when a supine client lifts his head is –– Do not attempt to reduce a femoral hernia caused by a separation between the left and right –– Use abdominal or groin truss for support abdominus rectus muscles (diastasis recti) is not a true hernia as the fasica is intact; the client may Client Education experience difficulty lifting due to the separation –– Explain disease process, expected course and –– Obesity may conceal hernias; multiple hernias need for follow-up is not uncommon; there is greater risk of –– Demonstrate application of truss, and encourage incarceration its daily use –– Strangulated abdominal hernia may present –– Demonstrate proper lifting techniques as a small bowel obstruction –– Teach client signs and symptoms of complications and advise him or her to return to the nursing DIFFERENTIAL DIAGNOSIS station if these occur Groin Hernia Pharmacologic Interventions –– Testicular torsion (acute emergency) Analgesia for discomfort: –– Epididymitis –– Epididymal cyst acetaminophen (Tylenol), 325 mg 1–2 tabs orally every 4–6 hours as required (maximum 4 g daily) –– Hydrocele –– Testicular mass or –– Dilated () acetaminophen with codeine (Tylenol #3), –– Enlarged inguinal lymph node 1–2 tabs orally every 4 hours as needed (maximum 4 g acetaminophen daily)

Clinical Practice Guidelines for Nurses in Primary Care 2011 5–28 Gastrointestinal System

Monitoring and Follow-Up Predisposing Factors Follow as necessary until surgical consult takes place. –– Possible genetic predisposition Monitor for the development of bowel obstruction –– Past bowel disturbance (laxative abuse, (see “Obstruction of the Small or Large Bowel” food sensitivity, antibiotics, infection) in the section “Emergencies of the Gastrointestinal –– Emotional stress System”). –– History of physical or sexual abuse

Referral HISTORY Arrange elective follow-up with physician for –– Usually begins before age 40 surgical consult. Medevac if there are symptoms –– More common in women of strangulation or bowel obstruction. –– Symptoms vague and long term –– Chronic condition with remissions and IRRITABLE BOWEL exacerbations 103,104,105,106,107,108,109,110,111,112,113, SYNDROME –– Various combinations of constipation, diarrhea, 114,115 abdominal pain and gas –– Constipation or diarrhea may be the dominant Irritable bowel syndrome is a functional bowel pattern disorder of abdominal pain associated with passing stool or with altered bowel habits and features of –– Diffuse lower-abdominal pain or discomfort disordered defecation (Rome III Criteria). –– Pain of variable intensity; may persist for hours or days Rome III Diagnostic Criteria for Irritable Bowel –– Looser, more frequent bowel movements may Syndrome115 occur with onset of pain Recurrent abdominal pain or discomfort, that –– Pain exacerbated by meals, bowel movements cannot be explained by structural or biochemical or stress abnormalities, for at least 3 months, with onset at least –– Pain relieved by defecation 6 months previously associated with 2 or more of the –– No interference with daily activities following: –– White mucus frequently present 1. improvement with defecation –– Bloating and flatulence 2. onset is associated with a change in the frequency –– Symptoms not associated with irritable syndrome of stool that require further investigation include: –– fever, weight loss or malaise 3. onset is associated with a change in the consistency –– nocturnal pain and diarrhea of stool (loose, watery, or pellet-like) –– or blood in stool Other associated symptoms to support a diagnosis –– Associated symptoms may include: may include: –– upper abdominal symptoms of dyspepsia, –– ≤ 3 stools per week nausea, belching –– ≥ 3 stools per day) –– dysmenorrhea –– lumpy/hard stool –– dyspareunia –– loose watery stools –– sexual function difficulties –– straining to pass stool –– urinary symptoms including frequency and –– urgency urgency –– sensation of incomplete bowel movement The history for irritable bowel syndrome requires –– passing mucus a careful correlation of the timing of symptoms and –– bloating the relationship with food intake and dietary content.

CAUSES –– Largely unknown

2011 Clinical Practice Guidelines for Nurses in Primary Care Gastrointestinal System 5–29

PHYSICAL FINDINGS –– Recommend that client consume an adequate –– Client may appear quite well or in mild distress amount of fluid when using bulking agents –– Abdomen may be distended –– Recommend elimination of nicotine and codeine- containing drugs –– Bowel sounds may be increased or decreased –– Teach relaxation techniques and emphasize the –– Colon may be tender and “rope-like” importance of exercise to help with stress-induced –– Compression of colon may reproduce symptoms symptoms DIFFERENTIAL DIAGNOSIS –– Assist client to identify specific stress factors that exacerbate symptoms –– Constipation –– Assist client to gain insight into identifiable –– Uncomplicated diverticular disease emotional factors –– Gastroenteritis –– Offer understanding and support, as this is an –– Food intolerance incompletely and poorly understood syndrome –– Inflammatory bowel disease –– Drug-induced diarrhea or constipation Pharmacologic Interventions –– Biliary colic The evidence regarding the benefits of fibre for IBS is limited, with greater benefit observed in constipation COMPLICATIONS dominant IBS.116 Nonetheless, a trial of a stool- –– Chronic abdominal symptoms bulking agent may be helpful in some clients: –– Analgesic dependence or abuse psyllium (Metamucil), 1–2 tsp (5–10 mL) orally two –– Absenteeism from work with flare-ups of pain or three times daily with 8 oz (250 mL) fluid The patient can obtain Metamucil with a prescription DIAGNOSTIC TESTS through an NIHB pharmacy provider. –– Test stool for occult blood May need to slowly increase the amount of fibre over –– Sample stool for culture and sensitivity several days to avoid worsening symptoms.116 –– Measure hemoglobin level –– Perform urinalysis Monitoring and Follow-Up

MANAGEMENT –– Follow up in 1–2 weeks –– Review effects of dietary changes on symptoms Goals of Treatment –– If on additional , adjust the dose –– Relieve symptoms depending on response –– Establish regular bowel habits –– Use less fibre temporarily if gas and bloating are prominent –– Identify or modify precipitating stresses –– Use more fibre if there has been little clinical Nonpharmacologic Interventions response

Client Education Referral –– Recommend dietary modifications (for example, Refer to a physician if symptoms or signs of organic regular meals, gradual increase of fibre) disease are present or if symptoms do not improve –– For clients with constipation-related symptoms with management. This can be a difficult condition of IBS, increase in fibre content of diet (for to manage. Most patients have chronic symptoms example, raw bran, brown bread, popcorn, All- that flare up periodically. Bran, Puffed Wheat or Shredded Wheat cereal); when raw (miller’s) bran is used, start with a small amount and increase gradually to ¼ to ½ cup daily to avoid bloating and flatulence –– Recommend avoidance of foods that are known to cause symptoms (these vary from person to person)

Clinical Practice Guidelines for Nurses in Primary Care 2011 5–30 Gastrointestinal System

PEPTIC ULCER DISEASE –– Nausea may be present (PUD)117,118,119,120,121,122,123 –– Melena or indicates complications –– Assess use of alcohol, acetylsalicylic acid (ASA), An ulceration of the of the upper NSAIDs, corticosteroids digestive tract. Usually refers to a duodenal or –– The natural history of a benign ulcer is that two- gastric ulcer. thirds will recur in the first year after treatment CAUSES PHYSICAL FINDINGS The two most common causes of PUD are bacterial Epigastric tenderness (mild-moderate). The acutely infection with (HP) and use of nonsteroidal anti-inflammatory drugs (NSAIDs). tender, rigid or distended abdomen may signal The use of NSAIDs in the presence of HP infection perforated ulcer. may increase the risk of developing PUD. Other less DIFFERENTIAL DIAGNOSIS common causes of PUD include other medications (for example, corticosteroids, bisphosphonates, –– Gastritis potassium chloride), gastric surgery (gastric bypass) –– Esophagitis inflammatory diseases (Crohn’s disease, sarcoidosis) –– Biliary colic and hypersecretion states (). –– GERD Risk Factors –– Irritable bowel syndrome –– Neoplasm –– Medications such as NSAIDs, corticosteroids –– Diverticulitis –– Severe physiological stress (illness, surgery) –– Pancreatitis –– Chronic gastritis –– Ischemic bowel disease –– Chronic lung or kidney disease –– Medications (NSAIDs, colchicine, corticosteroids, –– Smoking antibiotics, niacin, gemfibrozil, potassium –– Genetic factors supplements, digoxin, iron)

HISTORY COMPLICATIONS –– Symptoms may be vague or absent, classical –– Iron deficiency anemia (from chronic blood loss) or atypical (some people with a duodenal ulcer –– Severe pain have no symptoms, whereas some with ulcer-like symptoms have no ulcer) –– Sudden hemorrhage, which can lead to hypotension –– Chronic benign disease with recurrent –– Perforation exacerbations and remissions (typical with –– Peritonitis duodenal ulcers) –– Obstruction of the gastric outlet –– Symptoms usually occur in epigastrum near midline between xiphoid and umbilicus or in DIAGNOSTIC TESTS right upper quadrant and may radiate to the back –– Test stool for occult blood –– Discomfort is typically described as burning, –– Measure hemoglobin level gnawing, hunger-like –– Urinalysis –– May also describe vague or cramp-like sensation –– Diagnostic testing to confirm presence of or have heartburn H. pylori (must be ordered by a physician) –– Symptoms have variable intensity, from mild to moderate to severe MANAGEMENT –– Duodenal ulcer symptoms typically begin 2–5 hours after meals, when stomach becomes empty Goals of Treatment –– Gastric ulcer symptoms tend to occur soon after meals –– Relieve pain –– Night wakening with symptoms is common due to –– Reduce stomach acid high acid output from circadian rhythms (usually –– Promote healing between 11:00 p.m. and 2:00 a.m.) –– Eradication of H. pylori (if presence confirmed) –– Relieved by food, milk or antacids (less effective –– Prevent complications with gastric ulcers)

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Appropriate Consultation –– Minimizing caffeinated and highly acidic Suspected PUD requires consultation to initiate beverages (tea, coffee, colas, orange juice) treatment and/or diagnostic testing. –– Avoidance of alcohol –– Avoidance of causative medications (NSAIDs, Urgent consultation is appropriate for the following colchicine, corticosteroids, antibiotics, niacin, alarm symptoms: gemfibrozil, potassium supplements, digoxin, iron) –– Unintentional weight loss –– Smoking cessation –– Pain radiating to back, neck, jaws, left arm –– Teach client the signs of complications that should or shoulder be followed up immediately –– Difficult or painful swallowing –– Protracted vomiting Pharmacologic Interventions –– Anemia Proton pump inhibitors such as Losec are the treatment –– Active gastrointestinal bleeding (black stools, of choice for symptomatic relief. They must be hematemasis) (see “Gastrointestinal Bleeding ordered by a physician. (Upper and Lower)” in the section “Emergencies Anyone testing positive for H. pylori in the setting of of the Gastrointestinal System”) peptic ulcer will need to undergo triple-drug therapy –– Stool positive for occult blood for eradication, as ordered by a physician.

Nonpharmacologic Interventions Monitoring and Follow-Up Client Education Follow up in 2 weeks to assess response to therapy. –– Explain the nature of the disease and the expected Follow up again in 4–6 weeks. Discontinue medications outcome if symptoms have resolved. Post-treatment testing for –– Counsel client about appropriate use of eradication of H. pylori must occur 4–6 weeks after medications (dose, frequency, purpose and discontinuation of all H. pylori eradication regimens. importance of compliance) Referral –– Recommend: –– Small, frequent meals that are lightly spiced Refer to a physician if there is no improvement with or not spiced at all treatment or if there are alarm symptoms, including: –– Avoidance of all foods known to increase pain –– New GI symptoms in clients > 40 years (for example, large fatty meals) –– Persistent postprandial or nocturnal pain

EMERGENCIES OF THE GASTROINTESTINAL SYSTEM

ABDOMINAL PAIN (ACUTE)124,125 –– Gynecologic problems (Mittelschmerz [pain at the midpoint of menstrual cycle, presumably related Pain caused by a wide variety of more and less serious to ovulation], dysmenorrhea, pelvic inflammatory conditions. The location of the pain, including its disease) origin and pattern of radiation, time of onset, nature –– Pyelonephritis and associated symptoms, will frequently help in –– Peptic ulcer making the diagnosis. –– Dyspepsia CAUSES –– Urinary tract infection –– Functional cause Some of the more common causes of acute abdominal pain in adults are: –– Gastroenteritis –– Gallbladder disease –– Appendicitis

Clinical Practice Guidelines for Nurses in Primary Care 2011 5–32 Gastrointestinal System

HISTORY Abdominal Examination

Associated Symptoms Inspection –– Unintended weight loss may indicate malignancy Check contour (distention), symmetry, location or malabsorption of most severe pain, hernia, scars. –– Vomiting may be associated with acute Auscultation appendicitis, bowel obstruction or –– High-pitched bowel sounds suggest obstructive –– Diarrhea may suggest inflammatory bowel disease process or malabsorption –– Absent bowel sounds suggest ileus or obstruction –– Constipation may indicate cancer or obstipation –– Melena or blood per rectum indicates Palpation and Percussion gastrointestinal (GI) bleeding, which may be –– Muscle rigidity (voluntary or involuntary) associated with peptic ulcer disease, esophageal –– Localized tenderness, masses, pulsation, hernias, varices, colon cancer or inflammatory bowel peritoneal irritation (cough or jumping may also disease elicit “rebound”) –– Jaundice may suggest liver disease, hepatic/ –– Involuntary guarding pancreatic carcinoma, hemolysis, sickle cell anemia –– (pain on internal rotation of hip (G6PD [glucose-6-phosphate dehydrogenase] with and hip bent) deficiency), choledocholithiasis –– Psoas sign (pain when straight leg is raised against –– Renal problems often present with abdominal resistance above the knee) pain; consider urolithiasis, urinary tract infection (dysuria, frequency, urgency, or –– Murphy’s sign (right upper quadrant pain when testicular torsion) breathing in and pressing over the liver) –– Pelvic/suprapubic symptoms and/or vaginal –– Liver dimension and spleen dimension discharge may be associated with ectopic –– Tenderness of costovertebral angle pregnancy, pelvic inflammatory disease, ovarian –– Pelvic exam in women torsion or ruptured ovarian cyst –– Rectal exam to rule out GI bleeding, prostatitis, etc. (rectal examination should be used to add to the Medical History entire clinical picture) –– Other major illnesses –– Absence of rectal tenderness does not preclude –– Prior surgery or confirm diagnosis of appendicitis –– Prior studies performed for evaluation of Diagnostic Tests (If Available) abdominal problems –– Family history of similar complaints –– Hemoglobin –– Medications, especially digoxin, theophylline, –– White blood cell (WBC) count corticosteroids, tetracycline (for peptic ulcer –– Urinalysis disease), analgesics, antipyretics, antiemetics, –– Pregnancy test for all reproductive-age females, barbiturates, diuretics, bisphosphonates (for unless status is post-hysterectomy ) –– Chest x-ray (if available) to rule out pneumonia –– Sexual activity, menstrual history, birth control –– Stool for occult blood use, history of sexually transmitted disease, vaginal discharge, spotting or bleeding DIFFERENTIAL DIAGNOSIS See Table 4, Differential Diagnosis of Abdominal Pain. PHYSICAL EXAMINATION

Vital Signs –– Signs of shock, infection (elevated temperature) –– Signs of dehydration, with dry mucous membranes and decreased skin turgor

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Table 4 – Differential Diagnosis of Abdominal Pain Diagnosis Usual Location of Pain Comments Hepatitis, subphrenic abscess, RUQ; may radiate to right shoulder Elevated liver enzymes, jaundice hepatic abscess, neoplasm Cholecystitis, cholelithiasis, RUQ, mid-epigastric region; Sudden onset with associated nausea cholangitis radiates to back and right scapula and/or vomiting; elderly may have minimal or no associated pain; fever with cholangitis Pancreatitis, neoplasm Mid-epigastric region; May have signs of peritonitis, nausea and radiates to back vomiting, increased pain with any oral intake with pancreatitis Duodenal ulcer or gastric ulcer Mid-epigastric region, LUQ; radiation to Elderly may have minimal or no associated pain; back if posterior ulcer; peritoneal signs overt GI bleeding or hemodynamic instability with perforation with perforation Gastroenteritis Generalized, may radiate Crampy, nausea, vomiting and/or diarrhea Constipation, obstipation, Generalized, may radiate Abdominal distention, hyper-resonance, altered bowel obstruction; ileus bowel function Splenic or LUQ Hypotension and peritonitis if ruptured enlargement, rupture, infarct Aortic aneurysm Epigastric, periumbilical, especially into May be colicky; hypotension if ruptured back flanks; may present as epigastric or back pain, flank or hip pain Appendicitis Early: periumbilical; late: RLQ May present with peritoneal signs, especially in elderly people Crohn’s disease or ulcerative RLQ, LLQ or generalized Bloody diarrhea with ulcerative colitis, cramps, colitis; ischemic colitis elevated sedimentation rate, platelets with Crohn’s/ulcerative colitis. Sudden pain that resolves and followed by bloody diarrhea with ischemic colitis Mesenteric adenitis, ischemia RLQ with adenitis, epigastric, Adenitis causes pain secondary to enlarged periumbilical or generalized mesenteric nodes from streptococcal with ischemia pharyngitis; pain out of proportion to physical examination (may be changes in pulse and blood pressure), may have vomiting or diarrhea with ischemia Spontaneous bacterial peritonitis Generalized, with peritoneal signs Usually in alcoholic people, people with indwelling catheters and those on dialysis Diverticulitis Generally LLQ, but may be suprapubic, Clinical diagnosis (pain + diarrhea, vomiting, RLQ or generalized fever) Meckel’s diverticulum Below or to left of umbilicus May be recurrent; presents with rectal bleeding or intestinal obstruction Urolithiasis, nephrolithiasis, Either flank; may radiate to labia Intravenous pyelogram for lithiasis; aching, pyelonephritis or testicles constant pain, nitrites, blood and/or leukocytes in urine with pyelonephritis Cystitis Suprapubic Urinalysis may show blood and leukocytes Gynecologic disease, including Pain in pelvis, either adnexal area; Pregnancy test, cervical/vaginal cultures, ovarian cyst, neoplasm or radiation to groin; may also radiate ultrasonography to rule out ectopic pregnancy torsion, ectopic pregnancy, to right shoulder if free intraperitoneal and assess ovaries Mittelschmerz, PID bleeding Metabolic disease such Pain may be diffuse; may have Associated with nausea, vomiting and elevated as diabetic ketoacidosis, guarding blood sugars Addison’s disease

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Table 4 – Differential Diagnosis of Abdominal Pain Diagnosis Usual Location of Pain Comments Pneumonia, subphrenic RUQ. LUQ Cough, , +/-chest pain; abscess, pulmonary , nausea/vomiting and fever may also be present pneumothorax Cardiac ischemia, infarction, May present as epigastric pain; ECG to rule out cardiac disease, especially pericarditis, cardiac hepatopathy RUQ with cardiac hepatopathy if risk factors present; may be confused with esophageal reflux; signs of congestive heart failure with congestive hepatopathy RUQ = right upper quadrant, LUQ = left upper quadrant, RLQ = right lower quadrant, LLQ = left lower quadrant, PID = pelvic inflammatory disease, ECG = electrocardiogram.

MANAGEMENT Monitoring and Follow-Up

Initial Decision –– Monitor pain, airway, breathing, circulation (ABC), vital signs and any associated fluid losses closely Decide whether to manage in the community, consult –– Serial exams over a few hours may clarify the a physician or arrange for medical evacuation. diagnosis

Appropriate Consultation Referral Consult a physician if the diagnosis is unclear and Medevac for evaluation if diagnosis is uncertain the presentation appears serious or medical evacuation and the client’s condition warrants urgent evaluation. is required.

127,128,129 Adjuvant Therapy APPENDICITIS –– Start intravenous (IV) therapy with normal saline; Inflammation of the . decide on expected fluid losses and current level of hydration CAUSES –– Hydrate according to physician orders Obstruction of the opening of the appendix by stool, –– Insert nasogastric tube if upon consultation a edema from inflammatory bowel disease or parasites physician supports its use for vomiting, bleeding traps intestinal bacteria that multiply and cause or suspected bowel obstruction infection. –– Foley catheter HISTORY Nonpharmacologic Interventions The following outlines the classic pattern for acute –– Nothing by mouth until diagnosis is clear appendicitis; however, the client may complain of various forms of abdominal, rectal and back Pharmacologic Interventions pain depending on the location of the appendix. Although classic surgical teaching has been that Duration of symptoms is usually less than 48 hours; medication for pain may confuse the diagnosis of however, elderly patients commonly have a longer abdominal pain in the emergency setting, this is not pain history and up to 2% of patients report pain and supported by the literature. Opioid analgesics can other abdominal symptoms extending to two weeks increase client comfort and do not mask clinical or greater. findings or delay diagnosis.126 Unless the diagnosis –– Review: is clear, do not administer any analgesia until you –– history immediately prior to the onset of pain have consulted a physician. (include nonpain symptoms in recent past) Choice of medication will depend on the presentation –– symptoms of the attack and local signs and the severity of the pain as described and rated by –– order of the occurrence of the symptoms the client. –– date of the last normal menstrual period, any menstrual irregularity and recent sexual history for women

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–– Vague, diffuse periumbilical or epigastric pain DIFFERENTIAL DIAGNOSIS –– Pain shifts within hours to right lower quadrant –– Abdominal abscess –– Anorexia –– Gastroenteritis/ –– Nausea –– Diverticulitis –– Vomiting usually occurs a few hours after onset –– Pancreatitis of pain, but may not be present –– Biliary colic –– Low-grade fever may be present –– Cholecystitis –– Urinary frequency, dysuria, pyuria and hematuria –– Peptic ulcer disease or acute urinary retention may develop due to –– Small bowel obstruction proximity of the inflamed appendix to the bladder –– Crohn’s disease –– Diarrhea or constipation occurs in up to 18% of patients due to bowel irritation –– Mittelschmerz (ruptured follicular cyst) –– Ectopic pregnancy PHYSICAL FINDINGS –– Pelvic inflammatory disease Appendicitis is known as the “great mimic.” The –– Twisted ovarian cyst actual signs and symptoms depend on the location –– Pyelonephritis of the appendix within the abdomen. Presentation –– Renal colic is variable, depending on whether the client presents –– Mesenteric adenitis early or late in the evolution of the disease process. COMPLICATIONS –– Temperature may be mildly elevated –– Heart rate elevated (may be normal in early stage) –– Abscess –– Variable level of distress –– Localized peritonitis –– Client holds abdomen, walks slowly and slightly –– Perforation bent over, lies with knees bent –– Generalized peritonitis –– Bowel sounds variable: hyperactive to normal –– Sepsis in early stages; reduced to absent in later stage DIAGNOSTIC TESTS –– Localized tenderness in right lower quadrant (tenderness may migrate from left to right lower –– Perform WBC count, if possible quadrant) –– Perform urinalysis –– Muscle guarding in right lower quadrant –– Urine HCG in women of childbearing age (peritoneal irritation) (if no hysterectomy) –– Rebound tenderness may be present –– CBC –– Rectal exam: tenderness may be present in right lower quadrant if tip of appendix is near the rectum MANAGEMENT –– Pain in right lower quadrant with: Goals of Treatment –– flexion of the right hip against resistance just above the knee (psoas sign) –– Maintain hydration –– right hip and knee flexed and internally rotated –– Prevent complications (obturator sign) –– Manage pain –– left lower quadrant palpation for rebound tenderness (Rovsing’s sign) Appropriate Consultation –– voluntary cough (cough sign) Consult a physician as soon as possible. –– Diffuse tenderness may be present with late presentation (more common in the elderly)

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Adjuvant Therapy Antiemetic: –– Start IV therapy with normal saline to keep dimenhydramine 50 mg IM or IV slow push q4–6h vein open (not to exceed 400 mg/day) –– Adjust IV rate according to age and state of If transfer is delayed, discuss starting IV antibiotics hydration, and in consultation with a physician with a physician: –– Insert nasogastric tube if upon consultation a cefazolin (Ancef), 1 g IV q8h physician supports its use if abdominal distention is present and metronidazole (Flagyl), 500 mg IV q12h Nonpharmacologic Interventions –– Bed rest Monitoring and Follow-Up –– Nothing by mouth Monitor vital signs and general condition frequently.

Pharmacologic Interventions Referral Although classic surgical teaching has been that Medevac as soon as possible; surgical consult medication for pain may confuse the diagnosis of is required. abdominal pain in the emergency setting, this is not supported by the literature. Opioid analgesics can increase client comfort and do not mask clinical GASTROINTESTINAL BLEEDING 130,131,132,133,134,135,136 findings or delay diagnosis.126 Unless the diagnosis (UPPER AND LOWER) is clear, do not administer any analgesia until you Bleeding from the gastrointestinal tract (GI). Sudden, have consulted a physician. rapid loss of blood from the gastrointestinal tract can Analgesia: cause hemodynamic instability and be life threatening. GI bleeding is a complication of an existing condition morphine 5–10 mg IM or SC every 3–4 hours or disease process. or 2.5–5 mg IV slow push q3–4h prn CAUSES See Table 5, “Causes of Gastrointestinal Bleeding.”

Table 5 – Causes of Gastrointestinal Bleeding Category Upper GI Bleeding Lower GI Bleeding Inflammatory Peptic ulcer disease Diverticulitis Erosive gastritis Ulcerative or Crohn’s colitis Erosive esophagitis Enterocolitis Stress ulcer Radiation colitis Ischemic colitis Anatomical Mallory-Weiss tear* Anal fissure* Meckel’s diverticulum Diverticulosis Vascular Esophageal, gastric, Hemorrhoids* duodenal varices , Angiodysplasia, telangiectasia Mesenteric ischemia Tumour Benign/malignant Malignant or benign polyps Systemic Blood dyscrasias Blood dyscrasias *Rarely causes significant blood loss unless patient is anticoagulated or has a blood dyscrasia

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HISTORY Considerations in the Elderly

Upper Gastrointestinal Bleeding –– Have fewer symptoms prior to bleeding (for example, abdominal pain, symptoms of dyspepsia) –– Focused inquiry of possible GI symptoms –– Peptic ulcer disease most common cause of upper or disease: gastrointestinal bleeding due to: –– nonsteroidal anti-inflammatory drug use –– higher rate of aspirin and NSAID use –– peptic ulcer disease –– higher rate of Helicobacter pylori infection –– liver disease –– Higher rate of anticoagulant use, increasing risk –– alcohol use of blood loss –– gastroesophageal reflux disease –– More comorbid conditions (for example, vascular –– upper abdominal pain disease, respiratory disease) –– early satiety –– Greater risk of cancer –– unintended weight loss –– Higher rate of diverticular lower gastrointestinal –– difficult or painful swallowing bleeding –– chronology of symptoms –– Higher rate of complications and mortality –– timing of bleeding –– Greater risk of myocardial infarction due to –– estimated amount of blood loss higher rate of cardiovascular disease –– Hematemesis (vomiting of bright red blood PHYSICAL FINDINGS or coffee-ground emesis) –– Melena (black, tarry stools) –– Significant gastrointestinal bleeding may cause –– (passage of bright red blood from hemodynamic compromise including: rectum with severe upper gastrointestinal bleeding) –– increased heart rate –– Sudden weakness or fainting –– weak pulse –– Cramping abdominal pain relieved by vomiting –– respirations rapid or stooling –– blood pressure low-normal or decreased –– There may be minimal or no pain in the elderly –– postural blood pressure drop –– restlessness, confusion Lower Gastrointestinal Bleeding –– Client pale and anxious –– Focused inquiry of possible GI symptoms or disease: –– Client weak and sweaty –– diverticular disease –– Bright red blood in vomit –– inflammatory bowel disease –– Black tarry stool –– painful passage of stool (fissure, hemorrhoids) –– Maroon, bright red blood or clots in stool –– history of polyps –– Bowel sounds initially hyperactive due to blood –– personal or family history of bowel cancer in bowel –– estimated amount of blood loss –– Bowel sounds may become reduced or absent –– chronology of symptoms –– Mild-to-severe tenderness may be present –– timing of bleeding DIFFERENTIAL DIAGNOSIS –– symptoms of recent , fever, myalgia (suggests inflammatory bowel disease, Upper Gastrointestinal Bleeding infectious cause) –– changes in stool diameter –– Peptic ulcer –– history of abdominal or pelvic –– Varices –– Hematochezia –– Erosive gastritis –– Sudden weakness or fainting –– Erosive esophagitis –– May have painless bleeding or cramping abdominal –– Meckel’s diverticulum pain relieved by stooling

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Lower Gastrointestinal Bleeding Nonpharmacologic Interventions –– Diverticular disease –– Bed rest –– Inflammatory bowel disease –– Nothing by mouth –– Colon cancer –– Mesenteric ischemia Pharmacologic Interventions pantoprazole (Panto IV), 80 mg bolus over COMPLICATIONS 30 minutes then pantoprazole (Pantoloc) 8 mg/hour IV131 –– Hypotension –– Shock Monitoring and Follow-Up –– Myocardial infarction (in clients with underlying Monitor ABC, vital signs and general condition cardiac disease) closely, as active re-bleeding can occur. –– Death Referral DIAGNOSTIC TESTS Medevac as soon as possible. –– Measure hemoglobin –– Test stool for occult blood –– Check stool for gross blood OBSTRUCTION OF THE SMALL 137,138,139,140,141 –– ECG in elderly patients to assess for myocardial OR LARGE Blockage of small or large bowel (partial or complete, –– H. pylori blood antibody test mechanical or paralytic).

MANAGEMENT CAUSES

Goals of Treatment –– Small bowel: adhesions (75%), hernia, cancer, Crohn’s disease (strictures) –– Replace circulating blood volume –– Large bowel: cancer (60%), volvulus (5%), Appropriate Consultation diverticulitis (20%), fecal impaction Consult a physician as soon as possible after client HISTORY is stable. –– Pain Adjuvant Therapy –– Anorexia –– Nausea –– Oxygen 6–10 L/min or more prn; keep oxygen –– Vomiting saturation greater than 95% –– Inability to pass stool or gas –– Large-bore IV (16- to 18-gauge) with normal saline –– Abdominal distention –– Start a second IV line for volume replacement if there are signs of hypovolemia (see “Shock” in –– Other symptoms, depending upon underlying the section “General Emergency Situations” in the disease process chapter “General Emergencies and Major Trauma”) The exact symptoms of obstruction depend on the –– Adjust IV rate according to estimated volume location and severity of the obstruction. The higher depletion, pulse rate, blood pressure, postural blood the level of obstruction, the more acute and rapid pressure drop and age the onset of symptoms. –– Insert nasogastric tube if upon consultation a physician supports its use to empty the stomach Small-Bowel Obstruction for upper GI bleeding –– Pain moderate to severe –– Insert urinary catheter; monitor hourly urinary –– Intermittent waves of pain (every 4–5 minutes) output –– Relative comfort between waves of pain –– Constant severe pain if bowel strangulation (up to 40% of cases of small-bowel obstruction)

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–– Vomiting frequent, violent, bilious when –– Peristaltic rushes, high-pitched tinkling obstruction is high sounds present –– Vomiting feculent when obstruction is lower –– Later, bowel sounds are diminished or absent –– Abdominal distention; prominent when obstruction –– Tenderness due to distention may be present is low –– Tender localized hernia or mass (abscess, tumour, –– Reduced rectal gas and stool passage volvulus) –– Weakness –– Rebound tenderness and rigidity present if perforation, peritonitis or strangulation have Large-Bowel Obstruction occurred –– Pain moderately severe (generally less acute –– Presence of surgical scars than in small-bowel obstruction) –– Tympany to hyperresonance with percussion –– Colicky (due to air-filled bowel loops) –– Distention present, occurs early, may be severe –– Rectal exam: blood or stool may be present, –– Vomiting usually late and infrequent, may rectum may be empty, mass may be palpable be feculent if rectal cancer –– Reduced or absent rectal gas and stool –– Examine all hernial orifices, including both –– Sudden onset of severe pain is a classic femoral rings manifestation of volvulus DIFFERENTIAL DIAGNOSIS –– Change in size of stool indicative of possible cancer, increased risk if weight loss –– Gastroenteritis/Enteritis –– Cholecystitis Paralytic Ileus –– Constipation/Obstipation –– Obstruction of the bowel due to paralysis of the –– Diverticular disease muscle of the bowel wall, caused by generalized –– Appendicitis peritonitis, any acute inflammation of the abdomen, –– Inflammatory bowel disease with distention severe , any acute illness, or as a post- –– Perforated ulcer operative complication –– Pancreatitis –– Major symptom is distention, resulting in moderate –– Mesenteric ischemia discomfort –– Ovarian distortion, pelvic inflammatory disease, –– Pain may be absent, but cramping possible ectopic pregnancy –– Frequent vomiting or regurgitation of gastric contents –– “Silent” distended abdomen on examination COMPLICATIONS –– Perforation PHYSICAL FINDINGS –– Intra-abdominal abscess –– Heart rate normal or increased –– Strangulated segment of bowel –– Respiration normal or increased –– Sepsis –– Blood pressure normal or low –– Hypotension, shock –– Postural blood pressure drop may be present –– Death –– Fever, tachycardia and peritoneal signs suggest possible from strangulation DIAGNOSTIC TESTS –– Client appears mildly to severely ill –– Test stool for occult blood –– Client doubles over with waves of pain in small- –– Perform urinalysis bowel obstruction –– Measure hemoglobin (optional; may help –– Client pale, sweaty, anxious with diagnosis and treatment) –– Various degrees of abdominal distention –– WBC if available (increased) –– Hernia may be visible –– Contractions of bowel wall (peristalsis) may be seen –– Bowel sounds increased in early stages

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MANAGEMENT Referral

Goals of Treatment Medevac as soon as possible. –– Relieve distention PANCREATITIS (ACUTE)142,143,144,145,146,147 –– Maintain hydration –– Prevent complications Inflammation of the pancreas.

Appropriate Consultation –– Mild pancreatitis, 80% of cases, usually resolves in 5–7 days with symptomatic management and Consult physician as soon as possible. treatment of physiologic causes (for example, gallstones) Adjuvant Therapy –– Severe necrotizing pancreatitis causes significant –– Start a large-bore IV (16- or 18-gauge) with normal morbidity and is associated with death rate of up saline; replace volume deficits to 30%. Early identification and management is –– Adjust IV rate according to pulse, postural blood essential for these cases pressure drop, blood pressure, state of hydration, age, pre-existing medical problems (see “Shock” CAUSES in the section “General Emergency Situations” The most common causes of pancreatitis are in the chapter “General Emergencies and Major gallstones (35–40%) and alcohol use (35%). Trauma”) –– Gallstones (including biliary sludge and –– Aim for pulse < 100 bpm, systolic blood pressure microlithiasis) > 100 mm Hg –– Alcohol (excessive or chronic alcohol abuse, –– Insert nasogastric tube if upon consultation a recent alcohol binge) physician supports its use. Attach to low suction or to straight drainage –– Medications (for example, azathioprine, L-asparaginase, , thiazides, estrogens, –– Insert urinary catheter; measure hourly urinary tamoxifen, valproic acid, didanosine, pentamidine, output metronidazole, tetracycline, sulfasalazine, 5-ASA, Nonpharmacologic Interventions sulindac, salicylates, calcium) –– Abnormality of the (duodenal –– Bed rest obstruction, biliary stricture, tumours) –– Nothing by mouth –– Acute viral, bacterial or parasitic infection (mumps, coxsackie, hepatitis B, CMV, varicella- Pharmacologic Interventions zoster, HSV, HIV, mycoplasma, legionella, Analgesia if required: leptospira, salmonella, aspergillus, toxoplasma, morphine 5–10 mg IM or SC q3–4h or 2.5–5 mg IV cryptosporidium, ascaris) slow push q3–4h prn –– Biliary procedures or abdominal surgery (for example, ERCP) Antiemetic if required: –– Trauma dimenhydramine 50 mg IM or IV slow push q4–6h –– Autoimmune diseases (for example, , (not to exceed 400 mg/day) inflammatory bowel disease) If transfer is delayed, discuss starting IV antibiotics –– Hyperlipidemia: triglycerides > 11.3 mmol/L with a physician: –– Hypercalcemia cefazolin (Ancef), 1 g IV q8h –– Idiopathic and –– Genetic disorders –– Ischemic injury (from vasculitis, embolism, metronidazole (Flagyl), 500 mg IV q12h severe hypotension) Monitoring and Follow-Up Monitor ABC, vital signs, urinary output and general condition frequently.

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HISTORY –– Tender epigastrum with muscle guarding and –– A focused history is important to establishing rigidity (may have less epigastric tenderness pancreatitis as the cause of abdominal pain than expected given severity of pain) including: –– Jaundice (28% of patients) –– biliary disease or gallstones –– Severe cases may have bluish discoloration of –– alcohol use (onset of symptoms often the flanks (Grey Turner’s sign) and periumbilicus 1–3 days after binges) (Cullen’s sign) due to retroperitoneal bleeding from the injured pancreas –– current or recent use of prescription/ nonprescription medications or herbal, DIFFERENTIAL DIAGNOSIS alternative or traditional products –– autoimmune disorders –– Peptic ulcer disease –– family history of pancreatic disease (especially –– Severe gastritis in young patients with no alcohol history) –– Acute cholecystitis, cholangitis –– ERCP or other abdominal procedures –– Lower lobe pneumonia –– Upper abdominal pain, most commonly in the –– Intestinal obstruction epigastrum, but may also be right or left upper –– Aortic aneurysm quadrant –– Perforated viscous –– Rapid onset of pain that reaches maximum –– Pancreatic neoplasm intensity within 20 minutes –– Pain steady and penetrating in nature COMPLICATIONS –– May have band-like pain radiating through –– Hypotension to the back (occurs in ½ of patients) –– Shock –– Pain is relieved by sitting up and leaning forward, –– Paralytic ileus aggravated by lying down –– Thrombocytopenia –– Nausea and vomiting –– Sepsis –– Diarrheal symptoms may occur –– Hyperglycemia –– Abdominal distention (due to ileus, fluid collecting –– Adult respiratory distress syndrome in abdomen from pancreatic weeping) –– Death –– Shortness of breath (due to diaphragm irritation or pleural effusion) DIAGNOSTIC TESTS –– Jaundice (due to biliary obstruction) –– Measure blood glucose level (may be elevated) –– Weak, light-headed (may be significant –– Perform urinalysis if emodynamically unstable) –– Perform WBC count (if possible) PHYSICAL FINDINGS MANAGEMENT Physical findings reflect the severity of the attack. More severe disease is indicated by signs of shock. Goals of Treatment –– Temperature elevated (76% of patients) –– Relieve symptoms –– Heart rate elevated (65% of patients) –– Maintain hydration –– Blood pressure may be low (if in shock) or high –– Prevent complications (related to pain) Appropriate Consultation –– Postural blood pressure drop may be present –– Client anxious, in acute distress Consult a physician to establish diagnosis –– Distress increased when lying down and treatment plan. –– Abdomen distention (65% of patients) –– Bowel sounds reduced to absent (paralytic ileus) –– Respiratory findings may be present: basal crackles, left-sided atelectasis, pleural effusion (10% of patients)

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Adjuvant Therapy Pharmacologic Interventions –– Start a large-bore IV (16- or 18-gauge) with Analgesia: normal saline; replace volume deficits (may morphine 5–10 mg IM or SC q3-4h or 2.5–5 mg IV require significant fluid resuscitation)(see “Shock” slow push q3-4h prn in the section “General Emergency Situations” in the chapter “General Emergencies and Major or Trauma”) hyoscine butylbromide (Buscopan), 10–20 mg IV/IM –– Adjust rate according to pulse, postural blood q6-8h prn pressure drop, systolic blood pressure Antiemetics: –– Aim for pulse < 100 bpm, systolic blood pressure dimenhydrinate (Gravol), 50 mg IM q4-6h prn > 100 mm Hg (maximum dose 400 mg in 24 hours) –– Insert nasogastric tube if upon consultation a physician supports its use Monitoring and Follow-Up –– Insert a urinary catheter –– Measure hourly urinary output; adjust IV rate to –– Oxygen to maintain saturation of 95% (except maintain urine output at 0.5–1 mL/kg in adults148 with severe COPD) –– Stabilize blood pressure and pulse Nonpharmacologic Interventions –– Monitor blood glucose (hyperglycemia is common) –– Monitor pulse and blood pressure frequently until –– Bed rest the client’s condition stabilizes – watch for shock –– Nothing by mouth –– Monitor oxygenation –– Observe for alcohol withdrawal if a recent binge is a known cause of pancreatitis

Referral Medevac as soon as possible.

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103 Wilhelm SM, Brubaker CM, Varcak EA, 115 Chun AB, Wald A. (2009, May). Clinical Kale-Pradhan PB. Effectiveness of probiotics manifestations and diagnosis of irritable bowel in the treatment of irritable bowel syndrome. syndrome. Up To Date Online. Available by Pharmacotherapy 2008;28(4):496-505. Available subscription: www.uptodate.com at: http://www.medscape.com/viewarticle/572709 116 Thompson WG. (2009, November). Irritable 104 Reid G, Anukam K, Koyama T. Probiotic products bowel syndrome. www.e-therapeutics.ca in Canada with clinical evidence: What can 117 Soll AH. (2008, January). Overview of peptic ulcer: gastroenterologists recommend. Can J Gastroenterol Epidemiology and major causes. UpToDate Online. 2008;22(2):169-75. Available by subscription: www.uptodate.com 105 Quigley EMM. What is the evidence for the use 118 Soll AH. (2006, February). Clinical manifestations of probiotics in functional disorders? Current of peptic ulcer. UpToDate Online. Available by Gastroenterology Reports 2008;10:379-84. subscription: www.uptodate.com 106 Kajander K, Myllyluoma E, Rajulic-Stojanoic M, 119 Soll AH. (2008, January). Diagnosis of peptic ulcer. Kyronpalo S, et al. Clinical trial: Multispecies UpToDate Online. Available by subscription: probiotic supplementation alleviates the symptoms www.uptodate.com of irritable bowel syndrome and stabilizes intestinal 120 Soll A H. (2008, May). Complications of peptic microbiota. Alimentary Pharmacological Therapy ulcer. UpToDate Online. Available by subscription: 2006;27(1):48-57. Available at: http://www. http://www.uptodate.com medscape.com/viewarticle/568552_print 121 Peura DA. (2007, July). Management of duodenal 107 Tack J, Fried M, Houghton LA, Spcak J, Fisher G. ulcers in patients infected with Helicobacter pylori. Systematic review: The efficacy of treatments for UpToDate Online. Available by subscription: irritable bowel syndrome – A European perspective. www.uptodate.com Alimentary Pharmacological Therapy 2006;24(2): 183-205. Available at: http://www.medscape.com/ 122 Toward Optimized Practice; Clinical Practice viewarticle/537719_print Guidelines. Diagnosis and treatment of chronic undiagnosed dyspepsia in adults. 108 Lehrer JK, Lichtenstein GR. (2008, September). Alberta Medical Association, 2007. Available Irritable bowel syndrome. eMedicine. Available at: www.topalbertadoctors.org/download/353/ at: http://emedicine.com/met/TOPIC1190.HTM dyspepsia_guidline.pdf 109 Tougas G. Irritable bowel syndrome: New 123 Scaccianoce G, Hassan C, Panarese A, Piglionica approaches to its pharmacological management. D, et al. Helicobacter pylori eradications awith Can J Gastroenterol 2001;15 Suppl B:12B-13B either seven-day or 10-day triple therapies, and with 110 Ford AC, Talley NJ, Speigel BMR, Foxx-Orensetin a 10 day sequential regimen. Can J Gastroenterol AE, et al. Effect of fibre, antispasmodics, and 2006;20(2):113-17. peppermint oil in the treatment of irritable bowel 124 Flasar MH, Goldberg E. (2006). Acute abdominal syndrome: systematic review and meta-analysis. pain. Med Clin North Am;90:481-503. BMJ 2008;337:a2313. Available at: http://bmj.com/ cgi/content/ull/337/nov13_2/a2313 125 Lyon C, Clark DC. (2006). Diagnosis of acute abdominal pain in older patients. Available at: 111 Wald A. (2008, May). Treatment of irritable http://www.aafp.org/afp bowel syndrome. UpToDate Online. Available by subscription: www.uptodate.com 126 Manterola C, Astudillo P, Losada H, Pineda V, et al. (2007). Analgesia in patients with acute 112 Bernstein CN. Who gets irritable bowel abdominal pain. Cochrane Database of Systematic syndrome and does seeing a gastroenterologist Reviews, Issue 3. Art. No.: CD005660. DOI: affect its course? Can J Gastroenterol 2001;15 10.1002/14651858.CD005660.pub2. Available at: (Suppl 8):5B‑7B http://www.cochrane.org/reviews/en/ab005660.html 113 Longstreth GF, Thompson WG, Chey WD, 127 Craig S. (2008, September). Acute appendicitis. Houghton LA, et al. Functional bowel disorders. eMedicine. Available at: http://www.emedicine.com/ Gastroenterology 2006;130(5):1480-91. emerg/TOPIC41.HTM 114 Chun AB, Wald A. (2007, August). Pathophysiology 128 Sanacroce L, Ochoa JB. (2008, August). of irritable bowel syndrome. UpToDate Online. Appendicitis. eMedicine. Available at: http:// Available by subscription: www.uptodate.com www.emedicine.com/med/TOPIC3430.HTM 129 Goldberg JE, Hodin RA. (2008, September). UpToDate Online. Available by subscription: www.uptodate.com

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130 Jutabha R, Jensen DM. (2008, March). Major 145 Vege SS, Chari ST. (2008, September). Clinical causes of upper gastrointestinal bleeding in adults. manifestations and diagnosis of acute pancreatitis. UpToDate Online. Available by subscription: UpToDate Online. Available by subscription: www.uptodate.com http://www.uptodate.com 131 Jutabha R, Jensen DM. (2008, October). Approach 146 Vege SS, Chari ST. (2008, September). Treatment of to the adult patient with upper gastrointestinal acute pancreatitis. UpToDate Online. Available by bleeding in adults. UpToDate Online. Available subscription: www.uptodate.com by subscription: www.uptodate.com 147 Khoury G. (2007, July). Pancreatitis. eMedicine. 132 Jutabha R, Jensen DM. (2006, October). Etiology of Available at: http://www.emedicine.com/emerg/ lower gastrointestinal bleeding in adults. UpToDate TOPIC354.HTM Online. Available by subscription: www.uptodate.com 148 New South Wales (NSW) Health. NSW rural adult 133 Jutabha R, Jensen DM. (2008, September). Approach emergency clinical guidelines. 3rd ed. 2010 p. 112. to the adult patient with lower gastrointestinal bleeding in adults. UpToDate Online. Available by subscription: http://www.uptodate.com 134 Chico GF, Manas KJ. (2008, November). Lower gastrointestinal bleeding. eMedicine. Available at: http://www.emedicine.com/med/TOPIC3730.HTM 135 Yachimski PS, Friedman LS. (2008, January). Gastrointestinal beleeding in the elderly. eMedicine. Available at: http://www.medscape.com/ viewprogram/8635 136 Cerulli MA, Iqbal S. (2008, February). Upper gastrointestinal bleeding. eMedicine. Available at: http://www.emdedicine.com/med/TOPIC3565.HTM 137 Quickel R, Hodin RA. (2008, October). Clinical manifestations and diagnosis of small bowel obstruction. UpToDate Online 16.3. Available by subscription: www.uptodate.com 138 Quickel R, Hodin RA. (2008, October). Treatment of small bowel obstruction. UpToDate Online 16.3. 139 Hopkins C. (2011, November) Large bowel obstruction. eMedecine. Availible at: http:// emedicine.medscape.com/article/774045-overview 140 Basson MD. (2008, July). Colonic obstruction. eMedicine. Available at: http://www.emedicine.com/ med/TOPIC415.HTM 141 Nobie BA. (2007, September). Small bowel obstruction. eMedicine. Available at: http://www.emedicine.com/emerg/TOPIC66HTM 142 Barclay L, Lie D. (2008, June). Recommendations issued for acute pancreatitis. eMedicine. 143 Gardner TB. (2008, June). Acute pancreatitis. eMedicine. Available at: http://www.emedicine.com/ med/TOPIC1720.HTM 144 Vege SS, Chari ST. (2008, May). Etiology of acute pancreatitis. UpToDate Online.

2011 Clinical Practice Guidelines for Nurses in Primary Care