47
Lower Gastrointestinal Problems
Mariann M. Harding
http://evolve.elsevier.com/Lewis/medsurg/
CONCEPTUAL FOCUS
Cellular Regulation Inflammation
Elimination Nutrition
Fluid and Electrolytes Pain
Nutrition Stress and Coping
LEARNING OUTCOMES
1. Explain common causes and interprofessional and 6. Describe the clinical manifestations and interprofessional
nursing management of diarrhea, fecal incontinence, and and nursing management of colorectal cancer.
constipation. 7. Select nursing interventions to manage the care of the
2. Describe common causes of acute abdominal pain and patient after bowel resection and ostomy surgery.
nursing management of the patient after a laparotomy. 8. Distinguish between diverticulosis and diverticulitis,
3. Describe the interprofessional and nursing management including clinical manifestations and interprofessional and
of acute appendicitis, peritonitis, and gastroenteritis. nursing management.
4. Compare and contrast the inflammatory bowel diseases 9. Compare and contrast the types of hernias, including
of ulcerative colitis and Crohn’s disease, including etiology and surgical and nursing management.
pathophysiology, clinical manifestations, complications, 10. Describe the types of malabsorption syndromes and
and interprofessional and nursing management. interprofessional care of celiac disease, lactase deficiency,
5. Distinguish among small and large bowel obstructions, and short bowel syndrome.
including causes, clinical manifestations, and 11. Describe the types, clinical manifestations, and interpro
interprofessional and nursing management. fessional and nursing management of anorectal conditions.
KEY TERMS
anal fistula hemorrhoids
appendicitis hernia
bowel obstruction inflammatory bowel disease (IBD)
celiac disease irritable bowel syndrome (IBS)
constipation lactase deficiency
Crohn’s disease ostomy
diarrhea paralytic ileus
diverticulitis peritonitis
fecal incontinence short bowel syndrome (SBS)
fistula steatorrhea
gastroenteritis ulcerative colitis (UC)
The wide variety of gastrointestinal (GI) problems discussed in malabsorption problems. Conceptually, patients often have
this chapter include diarrhea, constipation, and fecal inconti problems with impaired elimination and nutrition. Many have
nence; inflammatory and infectious bowel problems; bowel inflammation and pain and are at risk for altered fluid and elec
trauma; bowel obstructions; colorectal cancer (CRC); abdom trolyte balance. Promoting optimal bowel habits and nutrition
inal and bowel surgery (including ostomy formation); and are common goals.
1088
, CHAPTER 47 Lower Gastrointestinal Problems 1089
3 days of being hospitalized. It is fairly common, developing in
DIARRHEA up to one-third of patients.
Diarrhea is the passage of at least 3 loose or liquid stools per
day. It may be acute, lasting 14 days or less, or persistent, lasting Etiology and Pathophysiology
longer than 14 days. Chronic diarrhea lasts 30 days or longer. The primary cause of acute diarrhea is ingesting infectious
Health care–associated diarrhea is acute diarrhea in a hospi organisms (Table 47.1). Viruses cause most cases of infectious
talized patient that was not present on admission and starts after diarrhea in the United States. While some viral infections can
TABLE 47.1 Causes and Manifestations of Acute Infectious Diarrhea
Type of Organism Manifestations Source of Infection/Susceptibility
Bacterial
Campylobacter • Diarrhea, abdominal cramps, fever. Sometimes nausea, vomiting • Undercooked poultry and unpasteurized milk
jejuni • Lasts about 7 days • Most frequent in summer months
Clostridioides • Watery diarrhea, fever, anorexia, nausea, abdominal pain • Prolonged use of antibiotics followed by exposure to feces-contami-
difficile nated surfaces
• Spores on hands and environmental surfaces are extremely hard to kill
Clostridium • Diarrhea, abdominal cramps, nausea, vomiting • Associated with meats, gravies, stews, dried or precooked foods
perfringens • Occurs 6–24 h after eating contaminated food and lasts • Can cause serious illness in anyone, especially older adults
about 24 h
Enterohemorrhagic • Severe abdominal cramping, bloody diarrhea, vomiting • Can cause serious illness, especially in older adults
Escherichia coli • Low-grade fever • May progress to life-threatening renal failure
(e.g., E. coli • Lasts 5–7 days • Transmitted in water or food contaminated with infected feces
O157:H7)
Enterotoxigenic • Watery or bloody diarrhea, abdominal cramps • Most common cause of travelers’ diarrhea
E. coli • Nausea, vomiting, fever may be present • Transmitted in water or food contaminated with infected feces
• Lasts 3–4 days
Salmonella • Diarrhea, fever, abdominal cramps • Reservoir is poultry, reptiles, and other animals (especially turtles,
• Lasts 4–7 days lizards, snakes, chicks, young birds)
• Can be transmitted by handling animals
• Found in undercooked poultry, meat, foods prepared with raw eggs
Shigella • Diarrhea (sometimes bloody), fever, stomach cramps • Transmitted via fecal-oral route or in food or water contaminated with
• Lasts 5–7 days infected feces
• Postinfection arthritis may occur • Can contaminate recreational water
Staphylococcus • Nausea, vomiting, abdominal cramps, diarrhea • 25%–50% of people are carriers in mucous membranes, skin, or hair
• Usually mild • Transmitted in food contaminated by food workers who are carriers or
• May cause illness in as little as 30 min through contaminated milk and cheese
• Lasts 1–3 days
Parasitic
Cryptosporidium • Watery diarrhea • Lives in human intestines
• Lasts about 2 weeks • Transmitted in stool of infected human or animal
• May have abdominal cramps, nausea, vomiting, fever, • Outer shell allows it to live for long periods outside of body and makes
dehydration, weight loss it resistant to chlorine
• May be fatal in those who are immunocompromised • Common cause of waterborne disease (swimming pools, lakes, drink-
(e.g., AIDS) ing water, food contaminated with feces)
Entamoeba • Diarrhea, abdominal cramping • Fecally contaminated food, water, or hands
histolytica • Only 10%–20% are ill, and symptoms are usually mild • Most common in tropical areas
• May last 2 weeks • In the United States, high-risk groups include travelers, recent immi-
grants, and men who have sex with men
Giardia lamblia • Abdominal cramps, nausea, diarrhea • Highly contagious
• May interfere with nutrient absorption • Transmitted via fecal-oral route
• Found in fresh lakes and rivers. Can be transmitted in swimming pools,
water parks, and hot tubs
Viral
Norovirus • Nausea, vomiting, diarrhea, stomach cramping • Very contagious
(Norwalk-like • Rapid onset • Virus is present in stool and emesis
virus) • Lasts 1–2 days
Rotavirus • Fever, vomiting, profuse watery diarrhea • Highly contagious
• Lasts 3–8 days • Transmitted mainly by fecal-oral route
,1090 SECTION 9 Problems of Ingestion, Digestion, Absorption, and Elimination
be deadly, most are mild and last less than 24 hours. So, most carbohydrate in the bowel, lactose intolerance, and certain lax
patients rarely seek treatment. atives (e.g., lactulose, sodium phosphate, magnesium citrate)
Bacterial infection with Escherichia coli O157:H7, a type of produce osmotic diarrhea. It results from rapid GI transit
enterohemorrhagic E. coli, is a common cause of bloody diar that prevents fluid and electrolyte absorption. Bile salts and
rhea in the United States. It is transmitted by undercooked beef undigested fats lead to excess fluid secretion into the GI tract.
or chicken contaminated with the bacteria or in fruits and veg Diarrhea from celiac disease and short bowel syndrome (SBS)
etables exposed to contaminated manure. Other pathologic E. result from malabsorption in the small intestine.
coli strains are endemic in developing countries and often cause
travelers’ diarrhea. Giardia lamblia is the most common GI par Clinical Manifestations
asite that causes diarrhea in the United States.1 Infections that attack the upper GI tract (e.g., Norovirus, G.
Infectious organisms attack the intestines in different ways. lamblia) usually produce large-volume, watery stools, cramp
Some organisms (e.g., Rotavirus A, Norovirus, G. lamblia) ing, and periumbilical pain (Table 47.1). Patients have either
change the secretion and/or absorption of enterocytes in the a low-grade or no fever and often have nausea and vomiting
small intestine. They do not cause inflammation. Other organ before diarrhea begins. Infections of the colon and distal small
isms (e.g., Clostridioides difficile) impair absorption by destroy bowel (e.g., Shigella, Salmonella, C. difficile) cause fever and fre
ing cells, causing inflammation in the colon, and producing quent bloody diarrhea with a small volume.
toxins that cause damage. Leukocytes, blood, and mucus may be present in the stool,
Secretory diarrhea is a common result of bacterial or viral depending on the causative agent. Severe diarrhea may cause
infections. It occurs when ingested pathogens survive in the GI life-threatening dehydration, electrolyte problems (e.g., hypo
tract long enough to absorb into the enterocytes. The resulting kalemia), and acid-base imbalances (metabolic acidosis). CDI
chain reaction changes cell permeability and causes the overse can progress to severe colitis and intestinal perforation.
cretion of water, sodium, and chloride into the bowel.
Organisms enter the body in contaminated food (e.g., Diagnostic Studies
Salmonella in undercooked eggs and chicken) or contaminated Stool cultures are usually done only in patients who are very ill;
drinking water (e.g., G. lamblia in contaminated lakes or pools). have a fever, bloody diarrhea, or diarrhea lasting longer than 3
Travelers often get diarrhea, especially if they travel to coun days; or were exposed during an outbreak. Those with travelers’
tries with poorer sanitation than their own. Infection can spread diarrhea lasting longer than 14 days should be assessed for par
from person to person via the fecal-oral route. For example, asitic infections. Stools are examined for blood, mucus, white
adult day care workers can transmit infection from one resident blood cells (WBCs), and parasites.1 Stool cultures tests can
to another if they do not wash their hands after changing soiled detect common viral, parasitic, and bacterial pathogens from a
diapers or linens. single stool sample.
A person’s age, gastric acidity, intestinal microflora, and Blood cultures should be done in those with signs of sepsis or
immune status influence their susceptibility to pathogens. Older systemic infection (e.g., high fever) or who are immunocompro
adults are most likely to have life-threatening diarrhea. Since mised. The WBC count may be high. People with long-standing
stomach acid kills ingested pathogens, taking drugs to decrease diarrhea can develop anemia from iron and folate deficiencies.
stomach acid (proton pump inhibitors [PPIs]) increases the Increased hematocrit, blood urea nitrogen (BUN), and creati
chance that pathogens will survive. nine levels are signs of fluid deficit.
The healthy human colon normally contains a variety of bac In patients with chronic diarrhea, measuring stool electro
teria, such as E. coli, viruses, and fungi we call the normal flora. lytes, pH, and osmolality helps determine whether the diarrhea
The normal flora aid in fermentation and provide a microbial is from decreased fluid absorption or increased fluid secretion.
barrier against pathogens. Antibiotics kill the normal flora, Measuring stool fat and undigested muscle fibers may show
making the person more susceptible to common viral, para fat and protein malabsorption conditions. Some patients with
sitic, and bacterial infections. For example, patients receiving secretory diarrhea have high serum levels of GI hormones, such
broad-spectrum antibiotics (e.g., carbapenems, cephalosporins) as vasoactive intestinal polypeptide and gastrin.
are susceptible to pathogenic strains of C. difficile. C. difficile
infection (CDI) causes the most serious hospital-associated Interprofessional Care
diarrhea and is a common cause of hospital-acquired GI illness. Treatment of diarrhea depends on the cause. Acute infectious
People who are immunocompromised because of disease (e.g., diarrhea is usually self-limiting. The major concerns are pre
human immunodeficiency virus [HIV]) or immunosuppressive venting transmission, replacing fluid and electrolytes, and pro
drugs are susceptible to GI tract infection. Immunocompromised tecting the skin. Most patients tolerate oral fluids. Solutions
patients receiving jejunal enteral nutrition (EN) are especially containing glucose and electrolytes may be enough to replace
prone to CDI and other foodborne infections. Jejunostomy and losses from mild diarrhea. If losses are severe, it will be neces
nasointestinal feedings, which bypass the stomach’s acid envi sary to give IV fluids, electrolytes, vitamins, and nutrition.
ronment, do not contain the poorly digestible fiber that normal Antidiarrheal drugs have limited short-term use. They coat
colonic bacteria need for survival. and protect mucous membranes, absorb irritating substances,
Diarrhea is not always due to infection. Drugs and food inhibit intestinal transit, decrease intestinal secretions, or
intolerances can cause diarrhea. Large amounts of undigested decrease central nervous system stimulation of the GI tract
, CHAPTER 47 Lower Gastrointestinal Problems 1091
TABLE 47.2 Drug Therapy
Antidiarrheal Drugs
Drug Mechanism of Action Nursing Considerations
bismuth subsalicylate (Pepto- Decreases secretions and has weak antibacterial activity. May cause tinnitus and confusion. Do not use with GI bleeding
Bismol) Used to prevent travelers’ diarrhea
difenoxin with atropine Decreases peristalsis and intestinal motility Caution patient to avoid alcohol. May cause drowsiness. Take as
directed. Overdose may be life-threatening.
diphenoxylate with atropine Opioid and anticholinergic. Decreases peristalsis and Blurred vision, dry mouth, drowsiness may occur. Take as
(Lomotil) intestinal motility directed. Overdose may be life-threatening.
loperamide (Imodium, Pepto Inhibits peristalsis, delays transit, increases absorption Caution patient to avoid alcohol. Do not use with GI bleeding.
Diarrhea Control) of fluid from stools May cause drowsiness. Use caution with hazardous activities.
octreotide acetate (Sandostatin) Suppresses serotonin secretion, stimulates fluid Given subcut, IM, IV. May cause gall bladder or liver problems.
absorption from GI tract, decreases intestinal motility
paregoric (camphorated tincture Opioid. Decreases peristalsis and intestinal motility Taken after each stool; up to 6 doses per day. May cause drowsi-
of opium) ness. Use caution with hazardous activities.
(Table 47.2). Antidiarrheal drugs are not used in treating some an enema, nasoenteral tube, or during colonoscopy. The major
infectious diarrheas because they potentially prolong expo concern with FMT is the potential for transmitting infectious
sure to the organism. They are used cautiously in inflamma agents in the donor stool. Using feces from donors who have
tory bowel disease (IBD) because of the danger of causing toxic intimate physical contact with the recipient and careful screen
megacolon (colon dilation greater than 5 cm). ing minimize this risk. Most patients have diarrhea right after
Antibiotics rarely have a role in treating acute diarrhea. They the procedure.
are given only for certain infections or when the infected per
son is severely ill or immunosuppressed. The 2 antibiotics rec NURSING MANAGEMENT: ACUTE INFECTIOUS
ommended for empiric therapy in adults are a fluoroquinolone, DIARRHEA
such as ciprofloxacin, and azithromycin.
Assessment
Clostridioides difficile infection Begin your assessment with a thorough history and physical
CDI is a particularly hazardous health care–associated infection assessment (Table 47.3). Ask the patient to describe their stool
(HAI). The risk for contracting CDI is highest in patients receiv pattern and related symptoms (Fig. 47.1). Focus on the dura
ing antimicrobial, chemotherapy, gastric acid–suppressing, or tion, frequency, character, and consistency of stool and the rela
immunosuppressive drugs.2 C. difficile spores can survive for up tionship to other symptoms, such as pain and vomiting. Ask
to 70 days on objects, including commodes, bedside tables, and about medical conditions that may cause diarrhea and whether
floors. Health care workers who do not adhere to strict infec the person is taking drugs, such as antibiotics and laxatives,
tion control precautions can transmit C. difficile from patient to which are known to cause diarrhea, decrease stomach acidity,
patient. Lactobacillus probiotics may be used to prevent CDI or or cause immunosuppression. Determine whether the patient
as an adjunct therapy to help prevent the risk for recurrent CDI. has traveled to a foreign country or been at a daycare facility
CDI is treated with either oral vancomycin (125 mg 4 times a recently. Ask if other family members are ill. Assess food prepa
day) or fidaxomicin (200 mg twice daily) for 10 days.3 All non ration practices, food intolerances (e.g., milk), and changes in
essential antibiotics, stool softeners, laxatives, and antidiarrheal diet and appetite.
drugs should be stopped. Metronidazole is an option when Assess for fever and signs of dehydration (dry skin, low-
patients cannot be treated with vancomycin or fidaxomicin. grade fever, orthostatic changes in pulse and BP, decreased and
Patients with severe, complicated CDI with shock, hypotension, concentrated urine). Assess the abdomen for distention, pain,
ileus, or megacolon should receive vancomycin 500 mg 4 times and guarding. Inspect the perineal skin for signs of redness and
daily orally with IV metronidazole.2 Patients with an ileus can breakdown from diarrhea.
receive vancomycin via enema.
Recurrent CDI occurs in about 20% of patients. The risk Clinical Problems
increases with the use of additional antibiotics and CDI recur Clinical problems for the patient with acute infectious diarrhea
rences. Fecal microbiota transplantation (FMT) is emerging as include:
an effective treatment for recurrent CDI.2 FMT reestablishes • Impaired bowel elimination
healthy intestinal flora by infusing fecal bacteria obtained • Fluid imbalance
from healthy donor stool into the patient’s colon. To per • Electrolyte imbalance
form an FMT, feces obtained from the donor is pureed into For more information on clinical problems and interven
a liquid slurry consistency using saline, water, or pasteurized tions for diarrhea, see eNursing Care Plan 47.1 on the website
cow’s milk. The donor stool is then placed in the GI tract via for this chapter.
Lower Gastrointestinal Problems
Mariann M. Harding
http://evolve.elsevier.com/Lewis/medsurg/
CONCEPTUAL FOCUS
Cellular Regulation Inflammation
Elimination Nutrition
Fluid and Electrolytes Pain
Nutrition Stress and Coping
LEARNING OUTCOMES
1. Explain common causes and interprofessional and 6. Describe the clinical manifestations and interprofessional
nursing management of diarrhea, fecal incontinence, and and nursing management of colorectal cancer.
constipation. 7. Select nursing interventions to manage the care of the
2. Describe common causes of acute abdominal pain and patient after bowel resection and ostomy surgery.
nursing management of the patient after a laparotomy. 8. Distinguish between diverticulosis and diverticulitis,
3. Describe the interprofessional and nursing management including clinical manifestations and interprofessional and
of acute appendicitis, peritonitis, and gastroenteritis. nursing management.
4. Compare and contrast the inflammatory bowel diseases 9. Compare and contrast the types of hernias, including
of ulcerative colitis and Crohn’s disease, including etiology and surgical and nursing management.
pathophysiology, clinical manifestations, complications, 10. Describe the types of malabsorption syndromes and
and interprofessional and nursing management. interprofessional care of celiac disease, lactase deficiency,
5. Distinguish among small and large bowel obstructions, and short bowel syndrome.
including causes, clinical manifestations, and 11. Describe the types, clinical manifestations, and interpro
interprofessional and nursing management. fessional and nursing management of anorectal conditions.
KEY TERMS
anal fistula hemorrhoids
appendicitis hernia
bowel obstruction inflammatory bowel disease (IBD)
celiac disease irritable bowel syndrome (IBS)
constipation lactase deficiency
Crohn’s disease ostomy
diarrhea paralytic ileus
diverticulitis peritonitis
fecal incontinence short bowel syndrome (SBS)
fistula steatorrhea
gastroenteritis ulcerative colitis (UC)
The wide variety of gastrointestinal (GI) problems discussed in malabsorption problems. Conceptually, patients often have
this chapter include diarrhea, constipation, and fecal inconti problems with impaired elimination and nutrition. Many have
nence; inflammatory and infectious bowel problems; bowel inflammation and pain and are at risk for altered fluid and elec
trauma; bowel obstructions; colorectal cancer (CRC); abdom trolyte balance. Promoting optimal bowel habits and nutrition
inal and bowel surgery (including ostomy formation); and are common goals.
1088
, CHAPTER 47 Lower Gastrointestinal Problems 1089
3 days of being hospitalized. It is fairly common, developing in
DIARRHEA up to one-third of patients.
Diarrhea is the passage of at least 3 loose or liquid stools per
day. It may be acute, lasting 14 days or less, or persistent, lasting Etiology and Pathophysiology
longer than 14 days. Chronic diarrhea lasts 30 days or longer. The primary cause of acute diarrhea is ingesting infectious
Health care–associated diarrhea is acute diarrhea in a hospi organisms (Table 47.1). Viruses cause most cases of infectious
talized patient that was not present on admission and starts after diarrhea in the United States. While some viral infections can
TABLE 47.1 Causes and Manifestations of Acute Infectious Diarrhea
Type of Organism Manifestations Source of Infection/Susceptibility
Bacterial
Campylobacter • Diarrhea, abdominal cramps, fever. Sometimes nausea, vomiting • Undercooked poultry and unpasteurized milk
jejuni • Lasts about 7 days • Most frequent in summer months
Clostridioides • Watery diarrhea, fever, anorexia, nausea, abdominal pain • Prolonged use of antibiotics followed by exposure to feces-contami-
difficile nated surfaces
• Spores on hands and environmental surfaces are extremely hard to kill
Clostridium • Diarrhea, abdominal cramps, nausea, vomiting • Associated with meats, gravies, stews, dried or precooked foods
perfringens • Occurs 6–24 h after eating contaminated food and lasts • Can cause serious illness in anyone, especially older adults
about 24 h
Enterohemorrhagic • Severe abdominal cramping, bloody diarrhea, vomiting • Can cause serious illness, especially in older adults
Escherichia coli • Low-grade fever • May progress to life-threatening renal failure
(e.g., E. coli • Lasts 5–7 days • Transmitted in water or food contaminated with infected feces
O157:H7)
Enterotoxigenic • Watery or bloody diarrhea, abdominal cramps • Most common cause of travelers’ diarrhea
E. coli • Nausea, vomiting, fever may be present • Transmitted in water or food contaminated with infected feces
• Lasts 3–4 days
Salmonella • Diarrhea, fever, abdominal cramps • Reservoir is poultry, reptiles, and other animals (especially turtles,
• Lasts 4–7 days lizards, snakes, chicks, young birds)
• Can be transmitted by handling animals
• Found in undercooked poultry, meat, foods prepared with raw eggs
Shigella • Diarrhea (sometimes bloody), fever, stomach cramps • Transmitted via fecal-oral route or in food or water contaminated with
• Lasts 5–7 days infected feces
• Postinfection arthritis may occur • Can contaminate recreational water
Staphylococcus • Nausea, vomiting, abdominal cramps, diarrhea • 25%–50% of people are carriers in mucous membranes, skin, or hair
• Usually mild • Transmitted in food contaminated by food workers who are carriers or
• May cause illness in as little as 30 min through contaminated milk and cheese
• Lasts 1–3 days
Parasitic
Cryptosporidium • Watery diarrhea • Lives in human intestines
• Lasts about 2 weeks • Transmitted in stool of infected human or animal
• May have abdominal cramps, nausea, vomiting, fever, • Outer shell allows it to live for long periods outside of body and makes
dehydration, weight loss it resistant to chlorine
• May be fatal in those who are immunocompromised • Common cause of waterborne disease (swimming pools, lakes, drink-
(e.g., AIDS) ing water, food contaminated with feces)
Entamoeba • Diarrhea, abdominal cramping • Fecally contaminated food, water, or hands
histolytica • Only 10%–20% are ill, and symptoms are usually mild • Most common in tropical areas
• May last 2 weeks • In the United States, high-risk groups include travelers, recent immi-
grants, and men who have sex with men
Giardia lamblia • Abdominal cramps, nausea, diarrhea • Highly contagious
• May interfere with nutrient absorption • Transmitted via fecal-oral route
• Found in fresh lakes and rivers. Can be transmitted in swimming pools,
water parks, and hot tubs
Viral
Norovirus • Nausea, vomiting, diarrhea, stomach cramping • Very contagious
(Norwalk-like • Rapid onset • Virus is present in stool and emesis
virus) • Lasts 1–2 days
Rotavirus • Fever, vomiting, profuse watery diarrhea • Highly contagious
• Lasts 3–8 days • Transmitted mainly by fecal-oral route
,1090 SECTION 9 Problems of Ingestion, Digestion, Absorption, and Elimination
be deadly, most are mild and last less than 24 hours. So, most carbohydrate in the bowel, lactose intolerance, and certain lax
patients rarely seek treatment. atives (e.g., lactulose, sodium phosphate, magnesium citrate)
Bacterial infection with Escherichia coli O157:H7, a type of produce osmotic diarrhea. It results from rapid GI transit
enterohemorrhagic E. coli, is a common cause of bloody diar that prevents fluid and electrolyte absorption. Bile salts and
rhea in the United States. It is transmitted by undercooked beef undigested fats lead to excess fluid secretion into the GI tract.
or chicken contaminated with the bacteria or in fruits and veg Diarrhea from celiac disease and short bowel syndrome (SBS)
etables exposed to contaminated manure. Other pathologic E. result from malabsorption in the small intestine.
coli strains are endemic in developing countries and often cause
travelers’ diarrhea. Giardia lamblia is the most common GI par Clinical Manifestations
asite that causes diarrhea in the United States.1 Infections that attack the upper GI tract (e.g., Norovirus, G.
Infectious organisms attack the intestines in different ways. lamblia) usually produce large-volume, watery stools, cramp
Some organisms (e.g., Rotavirus A, Norovirus, G. lamblia) ing, and periumbilical pain (Table 47.1). Patients have either
change the secretion and/or absorption of enterocytes in the a low-grade or no fever and often have nausea and vomiting
small intestine. They do not cause inflammation. Other organ before diarrhea begins. Infections of the colon and distal small
isms (e.g., Clostridioides difficile) impair absorption by destroy bowel (e.g., Shigella, Salmonella, C. difficile) cause fever and fre
ing cells, causing inflammation in the colon, and producing quent bloody diarrhea with a small volume.
toxins that cause damage. Leukocytes, blood, and mucus may be present in the stool,
Secretory diarrhea is a common result of bacterial or viral depending on the causative agent. Severe diarrhea may cause
infections. It occurs when ingested pathogens survive in the GI life-threatening dehydration, electrolyte problems (e.g., hypo
tract long enough to absorb into the enterocytes. The resulting kalemia), and acid-base imbalances (metabolic acidosis). CDI
chain reaction changes cell permeability and causes the overse can progress to severe colitis and intestinal perforation.
cretion of water, sodium, and chloride into the bowel.
Organisms enter the body in contaminated food (e.g., Diagnostic Studies
Salmonella in undercooked eggs and chicken) or contaminated Stool cultures are usually done only in patients who are very ill;
drinking water (e.g., G. lamblia in contaminated lakes or pools). have a fever, bloody diarrhea, or diarrhea lasting longer than 3
Travelers often get diarrhea, especially if they travel to coun days; or were exposed during an outbreak. Those with travelers’
tries with poorer sanitation than their own. Infection can spread diarrhea lasting longer than 14 days should be assessed for par
from person to person via the fecal-oral route. For example, asitic infections. Stools are examined for blood, mucus, white
adult day care workers can transmit infection from one resident blood cells (WBCs), and parasites.1 Stool cultures tests can
to another if they do not wash their hands after changing soiled detect common viral, parasitic, and bacterial pathogens from a
diapers or linens. single stool sample.
A person’s age, gastric acidity, intestinal microflora, and Blood cultures should be done in those with signs of sepsis or
immune status influence their susceptibility to pathogens. Older systemic infection (e.g., high fever) or who are immunocompro
adults are most likely to have life-threatening diarrhea. Since mised. The WBC count may be high. People with long-standing
stomach acid kills ingested pathogens, taking drugs to decrease diarrhea can develop anemia from iron and folate deficiencies.
stomach acid (proton pump inhibitors [PPIs]) increases the Increased hematocrit, blood urea nitrogen (BUN), and creati
chance that pathogens will survive. nine levels are signs of fluid deficit.
The healthy human colon normally contains a variety of bac In patients with chronic diarrhea, measuring stool electro
teria, such as E. coli, viruses, and fungi we call the normal flora. lytes, pH, and osmolality helps determine whether the diarrhea
The normal flora aid in fermentation and provide a microbial is from decreased fluid absorption or increased fluid secretion.
barrier against pathogens. Antibiotics kill the normal flora, Measuring stool fat and undigested muscle fibers may show
making the person more susceptible to common viral, para fat and protein malabsorption conditions. Some patients with
sitic, and bacterial infections. For example, patients receiving secretory diarrhea have high serum levels of GI hormones, such
broad-spectrum antibiotics (e.g., carbapenems, cephalosporins) as vasoactive intestinal polypeptide and gastrin.
are susceptible to pathogenic strains of C. difficile. C. difficile
infection (CDI) causes the most serious hospital-associated Interprofessional Care
diarrhea and is a common cause of hospital-acquired GI illness. Treatment of diarrhea depends on the cause. Acute infectious
People who are immunocompromised because of disease (e.g., diarrhea is usually self-limiting. The major concerns are pre
human immunodeficiency virus [HIV]) or immunosuppressive venting transmission, replacing fluid and electrolytes, and pro
drugs are susceptible to GI tract infection. Immunocompromised tecting the skin. Most patients tolerate oral fluids. Solutions
patients receiving jejunal enteral nutrition (EN) are especially containing glucose and electrolytes may be enough to replace
prone to CDI and other foodborne infections. Jejunostomy and losses from mild diarrhea. If losses are severe, it will be neces
nasointestinal feedings, which bypass the stomach’s acid envi sary to give IV fluids, electrolytes, vitamins, and nutrition.
ronment, do not contain the poorly digestible fiber that normal Antidiarrheal drugs have limited short-term use. They coat
colonic bacteria need for survival. and protect mucous membranes, absorb irritating substances,
Diarrhea is not always due to infection. Drugs and food inhibit intestinal transit, decrease intestinal secretions, or
intolerances can cause diarrhea. Large amounts of undigested decrease central nervous system stimulation of the GI tract
, CHAPTER 47 Lower Gastrointestinal Problems 1091
TABLE 47.2 Drug Therapy
Antidiarrheal Drugs
Drug Mechanism of Action Nursing Considerations
bismuth subsalicylate (Pepto- Decreases secretions and has weak antibacterial activity. May cause tinnitus and confusion. Do not use with GI bleeding
Bismol) Used to prevent travelers’ diarrhea
difenoxin with atropine Decreases peristalsis and intestinal motility Caution patient to avoid alcohol. May cause drowsiness. Take as
directed. Overdose may be life-threatening.
diphenoxylate with atropine Opioid and anticholinergic. Decreases peristalsis and Blurred vision, dry mouth, drowsiness may occur. Take as
(Lomotil) intestinal motility directed. Overdose may be life-threatening.
loperamide (Imodium, Pepto Inhibits peristalsis, delays transit, increases absorption Caution patient to avoid alcohol. Do not use with GI bleeding.
Diarrhea Control) of fluid from stools May cause drowsiness. Use caution with hazardous activities.
octreotide acetate (Sandostatin) Suppresses serotonin secretion, stimulates fluid Given subcut, IM, IV. May cause gall bladder or liver problems.
absorption from GI tract, decreases intestinal motility
paregoric (camphorated tincture Opioid. Decreases peristalsis and intestinal motility Taken after each stool; up to 6 doses per day. May cause drowsi-
of opium) ness. Use caution with hazardous activities.
(Table 47.2). Antidiarrheal drugs are not used in treating some an enema, nasoenteral tube, or during colonoscopy. The major
infectious diarrheas because they potentially prolong expo concern with FMT is the potential for transmitting infectious
sure to the organism. They are used cautiously in inflamma agents in the donor stool. Using feces from donors who have
tory bowel disease (IBD) because of the danger of causing toxic intimate physical contact with the recipient and careful screen
megacolon (colon dilation greater than 5 cm). ing minimize this risk. Most patients have diarrhea right after
Antibiotics rarely have a role in treating acute diarrhea. They the procedure.
are given only for certain infections or when the infected per
son is severely ill or immunosuppressed. The 2 antibiotics rec NURSING MANAGEMENT: ACUTE INFECTIOUS
ommended for empiric therapy in adults are a fluoroquinolone, DIARRHEA
such as ciprofloxacin, and azithromycin.
Assessment
Clostridioides difficile infection Begin your assessment with a thorough history and physical
CDI is a particularly hazardous health care–associated infection assessment (Table 47.3). Ask the patient to describe their stool
(HAI). The risk for contracting CDI is highest in patients receiv pattern and related symptoms (Fig. 47.1). Focus on the dura
ing antimicrobial, chemotherapy, gastric acid–suppressing, or tion, frequency, character, and consistency of stool and the rela
immunosuppressive drugs.2 C. difficile spores can survive for up tionship to other symptoms, such as pain and vomiting. Ask
to 70 days on objects, including commodes, bedside tables, and about medical conditions that may cause diarrhea and whether
floors. Health care workers who do not adhere to strict infec the person is taking drugs, such as antibiotics and laxatives,
tion control precautions can transmit C. difficile from patient to which are known to cause diarrhea, decrease stomach acidity,
patient. Lactobacillus probiotics may be used to prevent CDI or or cause immunosuppression. Determine whether the patient
as an adjunct therapy to help prevent the risk for recurrent CDI. has traveled to a foreign country or been at a daycare facility
CDI is treated with either oral vancomycin (125 mg 4 times a recently. Ask if other family members are ill. Assess food prepa
day) or fidaxomicin (200 mg twice daily) for 10 days.3 All non ration practices, food intolerances (e.g., milk), and changes in
essential antibiotics, stool softeners, laxatives, and antidiarrheal diet and appetite.
drugs should be stopped. Metronidazole is an option when Assess for fever and signs of dehydration (dry skin, low-
patients cannot be treated with vancomycin or fidaxomicin. grade fever, orthostatic changes in pulse and BP, decreased and
Patients with severe, complicated CDI with shock, hypotension, concentrated urine). Assess the abdomen for distention, pain,
ileus, or megacolon should receive vancomycin 500 mg 4 times and guarding. Inspect the perineal skin for signs of redness and
daily orally with IV metronidazole.2 Patients with an ileus can breakdown from diarrhea.
receive vancomycin via enema.
Recurrent CDI occurs in about 20% of patients. The risk Clinical Problems
increases with the use of additional antibiotics and CDI recur Clinical problems for the patient with acute infectious diarrhea
rences. Fecal microbiota transplantation (FMT) is emerging as include:
an effective treatment for recurrent CDI.2 FMT reestablishes • Impaired bowel elimination
healthy intestinal flora by infusing fecal bacteria obtained • Fluid imbalance
from healthy donor stool into the patient’s colon. To per • Electrolyte imbalance
form an FMT, feces obtained from the donor is pureed into For more information on clinical problems and interven
a liquid slurry consistency using saline, water, or pasteurized tions for diarrhea, see eNursing Care Plan 47.1 on the website
cow’s milk. The donor stool is then placed in the GI tract via for this chapter.
