1. Adult Medical Surgical Nursing
Gastro-intestinal Module:
Conditions of Malabsorption
Inflammatory Bowel Disorder: Crohn’s Disease; Ulcerative Colitis

2. Conditions of Malabsorption
Malabsorption is the inability of the intestinal mucosa to absorb one or more of the major nutrients

3. Conditions of Malabsorption
Infection: gastro-enteritis, amoeba, giardia
Post-intestinal surgery (resection)
Specific nutrient disorders: lactose intolerance, cystic fibrosis, coeliac
Maldigestion of fats (also fat-soluble vitamins ADEK): related to obstruction of bile flow into the intestine
Inflammatory bowel disorder: Crohn’s Disease and Ulcerative Colitis

4. Conditions of Malabsorption: Clinical Manifestations
Diarrhoea, watery or with blood, mucus and/ or pus
Frequent loose bulky offensive stools
Pale, grey fatty stools
Abdominal distension/ flatulence
Weakness, muscle-wasting, weight loss
Malnutrition and loss of well-being, dehydration
Vitamin deficiency, anaemia, bruising tendency, osteoporosis, osteomalacia

5. Conditions of Malabsorption: Diagnostic Tests
History and physical examination
Blood: CBC, ESR, CRP, Urea, Electrolytes, LFTs, Plasma proteins
Stool: analysis, culture, parasites, hour fat content, Guaic occult blood
Endoscopy
Colonoscopy
Barium or Gastrografin studies

6. Inflammatory Bowel Disorder
A chronic inflammatory condition which may relate to auto-immune disorder
There are two major conditions:
Crohn’s Disease (regional enteritis)
Ulcerative Colitis
Both conditions hold a risk for development of colon cancer

7. Crohn’s Disease

8. Crohn’s Disease: Pathophysiology
Sub-acute/ chronic inflammation of the distal ileum and ascending colon mainly
Mucosal ulceration in patches, separated by normal tissue
Ulceration may extend through all layers
Can cause perforation to the peritoneum
Inflammatory process leads to fibrosis, thickening the bowel wall and narrowing the lumen

9. Crohn’s Disease: Clinical Manifestations
Abdominal mild colicky pain (cramps from semi-obstruction)
Chronic diarrhoea (containing blood, mucus, pus): oedematous inflamed intestine with weeping irritating discharge
Weight loss, malnutrition, anaemia (chronic malabsorption), emaciation, dehydration
Fever and pain if abscesses
Acute severe pain/ shock if perforation
Remission and exacerbation

10. Crohn’s Disease: Diagnosis
Blood:
↑ WCC, ESR, CRP (inflammation)
↓ Hb, ↓ plasma proteins (albumen)
Electrolyte imbalance
Stool: blood, mucus, pus
Endoscopy/ colonoscopy: typical ulcerated patches seen
Barium or gastrografin studies: “string” sign, stricture/narrowing of intestinal lumen

11. Ulcerative Colitis

12. Ulcerative Colitis: Pathophysiology
Chronic inflammatory disease of the mucosa of the colon and rectum (10-15% will develop colon cancer)
Ulceration, desquamation and shedding of mucosa, bleeding, pus (severe protein loss)
Begins in rectum. May affect whole colon
Recurrent lesions, one after the other
Strictures and muscular hypertrophy

13. Ulcerative Colitis: Clinical Manifestations
Abdominal cramp-like pain (rebound tenderness right lower quadrant)
Diarrhoea (10-20 liquid stools daily with blood, mucus and pus in stool)
Rectal bleeding and urge to defaecate
Anorexia, severe weight loss, emaciation, muscle wasting, malnutrition, dehydration, anaemia, hypocalcaemia
Erythema, uveitis, arthritis (auto-immune)

14. Ulcerative Colitis: Diagnosis
Blood:
↑ WCC, ESR, CRP (inflammation)
↓ Hb, ↓ plasma proteins (serum albumen)
Electrolyte imbalance
Stool: frequent diarrhoea with pus, blood, mucus
Sigmoidoscopy: severe mucosal ulceration and shedding
Barium/ Gastrografin: shows shortening and dilatation of bowel (may perforate)

15. Inflammatory Bowel Disorder:
(Crohn’s Disease and Ulcerative Colitis)
Management

16. Inflammatory Bowel Disorder: Medical Treatment
Rest for the patient and for the bowel (to reduce inflammation and inappropriate immune response)
Nutrition and fluid replacement:
Encourage oral fluids
Intravenous infusion if electrolyte imbalance
Low-residue, high protein, high calorie diet as tolerated, with vitamin, minerals
Total Parenteral Nutrition (TPN)

17. Inflammatory Bowel Disorder: Medications
Sedatives and antispasmodics to control bowel motility and pain: Diazepam, Codeine Phosphate, Imodium, Buscopan
Antibiotics (Sulphonamides) to control secondary infection/ abscesses
Corticosteroids (oral and by enema): anti-inflammatory; immunomodulators if severe- lower immune response (Imuran)

18. Inflammatory Bowel Disorder: Surgery
Where conservative treatment fails or complications occur
Resection of the affected part of the intestine and ileostomy is performed above as a faecal diversion
May be temporary or permanent stoma*
May involve pouch of ileum (Kock pouch)
Contents of ileostomy drainage are fluid, contain proteolytic enzymes and are irritant to the skin (extreme care needed)

19. Post-Surgery Complications
Diarrhoea leading to dehydration and electrolyte imbalance: excessive fluid loss through stoma
Stomal stenosis/ retraction
Peri-stomal irritation/ excoriation (poorly-fitting pouch; proteolytic enzymes in fluid)
Psychological/ social implications
Renal calculi (dehydration)
Gall-stones (change in absorption of bile acids)

20. Inflammatory Bowel Disorder: Nursing Considerations
Emotional support (patient is often depressed)
Teaching about fluids, diet, medications, rest
Monitoring progress, stool frequency, fluid balance, electrolytes, weight, skin turgor
Post-surgery stoma care: check that stoma is pink and moist, no stenosis
Skin care: anti-fungal powder or barrier cream
Accurate fitting (and avoid frequent changing) of stomahesive patches (proteolytic enzymes)