Lower Gastrointestinal Problems: IBS, IBD, Colorectal Cancer – Flashcards

- Irritable Bowel Syndrom is a common, chronic disorder- NO organic cause is currently known - disorder NOT disease Symptoms - abdominal pain or discomfort - alterations in bowel patterns - intermittent and may occur for years - abdominal pain - diarrhea or constipation - excessive flatulence - bloating - urgency - sensation of incomplete evacuation Non-GI symptoms - fatigue - sleep disturbances

- patients often report history of GI infections and food intolerances- BUT, the role of food allergies in IBS is unclear - other dietary factors that may contribute to symptoms= fermentable oligo-, di-, and monosaccharides and polyols (FODMAPs)- examples- fractions found in wheat, galactans, lactose, fractures, sorbitol and xylitro- eliminate fake sugars - psychologic stressors (depression, anxiety, sexual abuse, PTSD) are associated with development and exacerbation

- women than in men

- NO specific physical findings to IBS - key to accurate diagnosis is a thorough history and physical examination - ask patients to describe symptoms, describe past health history, family history, drug, diet history - determine if and how IBS symptoms interfere with school, work, recreational activities - diagnostic tests are used to RULE out other disorders like- colorectal cancer, IBD, endometriosis, malabsorption disorders (celiac, lactose intolerance)

-Anemia - fever - persistent diarrhea - rectal bleeding - severe constipation - weight loss - this is the difference with inflammatory and irritable - will NOT have anemia with irritable, but will with inflammatory

- Recurrent abdominal pain or discomfort and a marked change in bowel habit for at least 6 months - symptoms are experienced on at least 3 days of at least 3 months - two or more of the following must apply *Pain is relieved by a bowel movement *Onset of pain is relegated to a a change in frequency of stool * Onset of pain is related to a change in appearance of stool

- treatment directed at psychologic and dietary factors and drugs to regulate stool output - patients more like to improve with treatment if have trusting relationship - encourage patient to verbalize concerns - since treatment is focused on symptoms, patient may benefit from keeping a diary of symptoms, diet and episodes and stress to ID factors that trigger - if tolerated, encourage the patient to have dietary fiber intake of 20g/day or to use a stool bulking agent- do this gradually to avoid bloating and gas - advise the patient whos primary symptoms are abdominal distention and flats to avoid gas-production foods- broccoli and cabbage, brown beans, Brussel sprouts, cauliflower, raw onion, grapes, plums raisins for example ------ yogurt may be BETTER tolerated than milk products ---- probiotics may be used b/c alterations in intestinal bacteria are believed to exacerbate the condition

- Loperamide- a synthetic opioid that slows intestinal transit, may be used to treat diarrhea when it occurs - Alosteron (Lotronex) a serotonergic antagonist is used for IBS patients when severe symptoms of pain and diarrhea - because of serious side effects (severe constipation, ischemic colitis) alosteron is available only in a restricted access program for women who have NOT responded to other IBS therapies - Lubiprostone (Amitiza) is approved for treatment of IBS with consitpation in women - Linaclotide (Linzess) is approved for the treatment of IBS with constipation in men and women

- patients may expereince severe constipation and ischemic colitis (reduced blood flow to intestines) - if constipation occurs, drug should be discontinued - symptoms of ischemic colitis- abdominal pain, blood in stool

- cognitive- behavioral therapy- stress management techniques, acupuncture, hypnosis - low doses of tricyclic antidepressants seem beneficial because decrease peripheral nerve sensitivity - no single therapy effective for all patients with IBS***

- for IBS - Used to treat incidences of diarrhea Synthetic opioid Decreases intestinal transit If alternating between diarrhea and constipation may not be the best idea OTC *Diarrhea --> especially LOW potassium, maybe low magnesium

Men - report manifestations of diarrhea more commonly than women - less likely to admit to symptoms or seek help compared to women Women - affects women 2-2.5 times more often - report manifestations more constipation than men - report more extra intestinal co-morbidities- migraine, insomnia etc. than men - Alosteron (Lotronex)- antidiarrheal approved only for women with severe IBS diarrhea

- chronic inflammation of the GI tract - characterized by periods of remission interspersed with periods of exacerbation - exact cause is unknown, no cure - classified as either 1. Chron's disease- can involve any segment of the GI tract from mouth to anus 2. Ulcerative Colitis- usually limited to the colon - The colon is also called the large intestine. The ileum (last part of the small intestine) connects to the cecum (first part of the colon) in the lower right abdomen. The rest of the colon is divided into four parts: -The ascending colon travels up the right side of the abdomen. • The transverse colon runs across the abdomen. • The descending colon travels down the left abdomen. • The sigmoid colon is a short curving of the colon, just before the rectum. - based on clinical manifestations - both commonly occur during the teenage years and early adulthood, both have a second peak in the 6th decade - IBD is more prevalent in industrialized countries and Ashkenazi Jews - many people with IBD have a family member with the disorder

UC: - teens to mid-30s onset Diarrhea- common - Abdominal cramping- common Fever- intermittent- during acute attacks - Weight loss- rare - Rectal bleeding- common Tenesmus- Common Malabsorption and nutritional deficiencies- minimal incidence Crohn's Disease - teens to mid 30s onset - diarrhea- common - abdominal crmaping- common - fever intermittent- common Weight loss- common, may be severe - rectal bleeding- infrequent - Tenesmus- rare - Malabsorption and nutritional differences- common

UC: - Location: usually starts in rectum and spreads in a continuous pattern up the colon - Distribution: Continuous areas of inflammation Depth of involvement: Mucosa and submucosa Granulomas noted on biopsy: occasional Cobble-stoning of Mucosa: Rare Pseudopolyps: Common Small bowel involvement: Minimal Crohn's Disease: - Location: Occurs anywhere along GI tract in characteristic skip lesions. Most frequent site is the ileum - Distribution: Healthy tissue interspersed with areas of inflammation- skin lesions Depth of involvement: entire thickness of bowel wall - transmural Granulomas noted on biopsy: common Cobble-stoning of Mucosa: common Pseudopolyps: rare Small bowel involvement: common

UC: - Fistulas: rare - Strictures: occasional - Anal abscesses: rare - Perforation: common b/c of toxic megacolon - Toxic megacolon: Relatively more common - Carcinoma: Increased incidence of colorectal cancer after 10 years of disease Recurrence after surgery: *Cure with colectomy Crohn's Disease: - Fistulas: common - Strictures: common - Anal abscesses: common - Perforation: common b/c inflammation involves entire bowel wall - Toxic megacolon: rare - Carcinoma: Increased incidence of small intestinal cancer. Increased incidence of colorectal cancer but not as much as with UC Recurrence after surgery: Common at site of anastomosis

- autoimmune disease involving an immune reaction against intestinal tract - some agent or combination - evidence suggests IBD is caused by combination of factors including environemntal factors, genetic predisposition, and alterations in functions of the immune system - environmental factors- diet, hygiene, stress, smoking, and NSAID increase susceptibility by influencing the environment of the microbial flora and the immune system - IBD is more prevalent in the industrialized regions of the world - specific dietary components have not been recognized - however, a high dietary intake of total fats, polyunsaturated fatty acids, omega-6 fatty acids, and meat is associated with increased risk of IBD - high fiber and fruit is associated with decreased risk of Crohn's disease - veges intake is assoicated with decreased risk of UC **Incidence is 4x higher among whites than other ethic groups

- IBD occurs more frequently in whites- particularly those of Jewish descent and in family members of persons with IBD- especially monzygotic twins - genetic predisposition has been confirmed by many - genetic mutations assoicated with CD or UC or both - NOD2 gene assoicated with CD - still research going

CD: - CD: the inflammation involves all layers of the bowel wall - CD can occur anywhere in the GI tract from mouth to anus, most commonly in the TERMINAL ILEUM- distal part of small intestine connects to colon- and COLON -in CD, segments of normal bowel can occur between disease portions, = so called skip lesions - ulcerations are deep and longitudinal and penetrate between islands of inflamed edematous mucosa, causing classic cobblestone appearance - strictures at ideas of inflammation may cause bowel obstruction - since inflammation goes through entire wall, microscopic leaks can allow bowel contents to enter peritoneal cavity and form abscesses or produce peritonitis - fistulas can develop between adjacent areas of the bowel, between bowel and bladder, bowel and vagina or skin to outside of the body - UTI= first sign of bowel or bladder fistula and feces is sometimes seen in the urine - fistula between bowel and vagina allow feces to leak out through the vagina - fistula with skin allow feces to leak out in skin UC - usually starts in the reectum and moves in a continual fashion toward cecum - mild inflammation may occur in terminal ileum, usually a disease of colon and rectum though - inflammation and ulcerations occur in the mucosal layer the innermost layer of the bowel wall- does not extend through all layers therefore fistulas and abscesses are rare - water and electrolytes cannot be absorbed through inflamed mucosa - diarrhea with large fluid/electrolyte loss - characteristic feature of damage to colonic mucosa epithelium - breakdown of cells --> protein loss through stool - area of inflamed mucosa form pseudopolyps

- often the same- diarrhea, bloody stools, weight loss, abdominal pain, fever, fatigue - bloody stools more common with UC - weight loss more common in CD beaus inflammation of small intestine impairs nutrient absorption - both are chronic with mild to severe acute exacerbations that occur unpredictable intervals over many years - rectal bleeding sometimes occurs in CD but more common in UC - in UC- primary manifestations are bloody diarrhea and abdominal pain - with mild UC- diarrhea consists of no more than 4 semiformal stools daily with small blood and no other manifestations - moderate UC- up to 10 stools.day, increased needling, systemic symptoms- fever, malaise, mild anemia, anorexia - severe disease- diarrhea is bloody, contains mucus and occurs 10-20x a day- ever rapid weight loos >10% body weight, anemia, tachycardia, and dehydration are present

- Local- confined to GI tract and systemic (extra-intestinal complications) Extra-intestinal Complications - Joints- arthritis, sacroiliitis, finger clubbing - Skin- erythema nudism - Mouth- pathos ulcers - Eyes- conjunctivitis, uveitis - gall stones - kidney stones - liver disease - osteoporosis Local Complications - hemorrhage, strictures, perforation, fistulas, colonic dilation (toxic megacolon) - patients with megacolon are at risk of perforation and may need emergency colectomy- more common in UC - perineal abscess and fistulas occur in 1/3 of patients with CD - incidence and severity of C diff in patients with IBD is increasing

-*Nutritional problems are especially common in CD when terminal ileum is involved- Bile salts and cobalamin are exclusively absorbed in the terminal ileum--> fat malabsorption and anemia

- need to rule out other diseases - in early CD symptoms can be similar to IBS - CBC will show iron deficiency anemia from blood loss - elevated WBC may be indication of toxic megacolon or perforation - decreased serum sodium, potassium, chloride, bicarbonate, magnesium levels due to fluid and electrolyte losses from diarrhea and vomiting - Hypoalbuminemia is present with severe disease as a result of poor nutrition or protein loss - elevated erythrocyte sedimentation rate, C-reactive protein and WBCs reflect inflammation - stool cultures determine if infection is there - stool examined for blood, pus, mucus - Imaging studies- double contrast barium enema, small bowel series, transabdominal ultrasound, CT, MRI- for IBD - colonoscopy allows for examination of ENTIRE large intestine lumen and sometimes most distal ileum********- extent of inflammation, ulcerations, pseudo polyps, and strictures is deterred and biopsy species taken for definitive diagnosis - colonoscopy can enter only distal ileum, capsule endoscopy may be used in the diagnosis of Chron's disease in the small intestine- but biopsy cannot be obtained by capsule endoscopy or barium enema

Goals of treatment 1. rest the bowel 2. control the inflammation 3. combat infection 4. Correct malnutrition 5. Alleviate any stress 6. Provide symptomatic relief 7. Improve QOL - hospitalization if patient fails to respond to drug treatment - since recurrent rate is high after surgical treatment of Crohn's, drugs are the preferred treatment

5 major classes - aminosalicylates - antimicrobials - corticosteroids - immunosuppressants - biologic and targeted therapy- do not work for everyone and expensive - drugs chosen on action and severity of inflammation - corticosteroids are given for shortest possible time because of side effects with long term use - patients with diseased left colon, sigmoid and rectum can be given suppositories, enemas, foams that deliver corticosteroid directly to the inflamed tissue with inimical systemic effects - immunosuppressants given to maintain remission after corticosteroid induction therapy - require regular CBC monitoring because they can suppress the bone marrow and --> inflammation of pancreas or gallbladder and delayed onset not good for acute flare ups *ask if we need to know all this page 979

- drainage of abdominal abscess - failure to respond to therapy - fistulas - inability to decrease corticosteroids - intestinal obstruction - massive hemorrhage - perforation - severe anorectal disease - suspicion of carcinoma

- since UC only affects the colon a total proctocolectomy is curative - surgeries include 1. Total proctocolectomy with ill pouch/anal anastomosis 2. Total proctocolectomy with permanent ileostomy - surgical procedures for UC can be performed laparoscopy

- most commonly used surgical procedure - a diverting ileostomy is performed and an ideal punch is created and anastomosed directly to the anus - the 2 surgical procedures are performed 8-12 weeks apart - initial procedure includes colectomy, rectal mucosectomy, ileal pouch (reservoir) construction, ileoanal anastomosis and temporary ileostomy - second surgery involves closure of the ileostomy to direct stool towards the new pouch - adaption of the pouch occurs over next 3-6 months which usually results in decreased number of bowel movements - patient is able to control defectation at the anal sphincter - major complication- acute or chronic pouchitis

- one stage operation removal of the colon, rectum and anus with closure of the anal opening - the end of the terminal ileum is brought out through the abdominal wall and forms a stoma or ostomy - stoma is usually placed in RLQ below belt line - with permeant ileostomy, continence is not possible

- usually performed for complications like strictures, obstructions, bleeding, fistula - most patients with CD eventually require surgery - when segments of the intestines are removed, the remaining intestine is reanastomsed - unfortunately, the disease often recurs at the anastomosis site - repeated removal of secretions of small intestine can lead to short bowel syndrome- occurs when surgery or disease leaves too little small intestine SA To maintain life--> lifetime parenteral nutrition is necessary for survival - conservative surgery is advocated instead of respective surgery in patients with CD- strictures obstructing the bowel can be widened with strictureplasty - if perforation allows bowel contents to drain into abdominal cavity surgery drains purulent material, irrigates the abdomen and makes a temporary ostomy - abscesses are surgically drained

- if ileostomy is formed, stoma viability, the mucocutaneous juncture (area where mucous membrane of the bowel interfaces with the skin) and peristomal skin integrity must be monitored - after surgery ileostomy output initially may be as high as 1500-2000mL/24hr: 60-80 mL/hr - observe s/s of hemorrhage, abdominal abscess, small bowel obstruction, dehydration etc. - if NG tube is used remove it when bowel function returns - patients especially with CD are at risk of early postoperative bowel obstruction, within 30 days -Transient incontince of mucus is a result of intraoperative manipulation of the anal canal - initial drainage through the illegal anastomosis will be liquid - kegal exercises may help strengthen pelvic floor and sphincter muscles- BUT THEY ARE NOT recommended in the immediate post-op period - perianal skin care is important to protect the epidermis from mucous drainage and maceration - instruct the patient to gently clean the skin with a mild cleanser, rinse well and dry complete - moisture barrier ointment and perineal pad may be used

-consult dietitian - nutritional deficiencies due to decreased oral intake, blood loss and depending on location of inflammation malabsorption of nutrients - inflammatory mediators reduce appetite - blood diarrhea --> iron deficiency anemia treated with supplemental iron (ferrous sulfate or ferrous gluconate) - parenteral iron may be needed if cannot tolerate PO iron - Iron dextran (Imferon) given IM Z tract or IV injection may be necessary if severe anemia - disease of terminal ileum reduces absorption of cobalamin and bile acids ---- reduced cobalamin contributes to anemia ---- bile salts important for fat absorption and contribute to osmotic diarrhea - cobalamin is available in injection form, given monthly or as a daily oral or nasal spray - Zinc deficiency can result from severe or chronic diarrhea and supplementation may be needed

- medications contirubte to nutrition problems -Patients with sulfasalazine should receive folate daily - those with corticosteroids are prone to osteoporosis and need calcium supplementations, potassium supplements may also be necessary ----corticosteroids can lead to sodium retention, hypokalemia and potential toxic megacolon - vitamin D deficiency is more common in IBD - need balance healthy diet with sufficient calories, protein and nutrients can use Myplate guidelines - diet for each patient must be individualized

- during acute exacerbation may not be able to tolerate regular diet - liquid enteral feedings are preferred over parenteral nutrition because atrophy of the gut and bacterial overgrowth occur when the GI tract is not used***** - enteral nutrition is high in calories and nutrients, lactose free and easily absorbed - enternal feedings help achieve remission and improve nutritional status - when regular foods are restarted add gradually note no universal food triggers for IBD, keep diary helps - many IBD are lactose intolerant symptoms improve when milk and milk products are avoided - can use yogurt as a substitute - high fat foods also trigger diarrhea - cold foods and high fiber foods (cereal with bran, nuts, raw fruits with peels) may promote diarrhea - smoking stimulates GI tract - increases motility and secretion- should be avoided

- during acute phase focus on hemodynamic stability, pain control, fluid and electrolyte balance, nutritional support - maintain accurate I/O, number and appearance of stools - trust relationship they do not feel in control - psychotherapy and behavioral therapies may help - need to accept illness - may suffer severe fatigue that limits energy for PA rest is important, may lose sleep because of diarrhea - until diarrhea is controlled help the patient stay clean, dry and free of odor - place deodorizer in the room - meticulous perianal skin care using PLAIN WATER no harsh soap with a skin barrier cream prevents breakdown - Dibucaine (Nupercainal) witch hazel or other soothing compresses or prescribed ointment and sitz bath my reduce irritation and discomfort to the anus * remember characterized by intermittent exacerbation and remission of symptoms

- second peak in 6th decade (despite being disease of teenagers and young adults) - in older patients with UC, the distal colon (proctitis) is usually involved* - diagnosis is sometimes difficult because confused with C diff or diverticulosis or NSAID - because of increased risk of CVD and pulmonary complications, older adults have increased morbidity with surgical procedures - older adults are also vulnerable to inflammation of the colon- colitis from drug use and systemic vascular disease - if renal function impaired may have more volume depletion consequences r/t diarrhea be aware

- third most common form of cancer - responsible for 9% of cancer deaths - more common in MEN than women - mortality rates highest among AA men and women - risks increase with age - 90% of CFC cases detected in people older than 50 - however, incidence of CRC in individuals over 50 is decreasing due to increased screening to detect precancerous lesions

RF for CRC include - diet high in red or processed meat - obesity - physical inactivity - alcohol - long term smoking - low intake of fruits and veggies - genetic conditions like FAP and a personal history of IBD place an individual at risk - 1/3 of cases of CRC occur in patients with a family history of CRC - Hereditary diseases (FAP) accounts for 5-10% of CRC cases - Physical exercise and a diet with large amounts of fruits, vegetables and grains may decrease risk CRC - long term use of NSAIDs is assoicated with reduced CRC

- Adenocarcinoma is most common - typically begins with adenomatous polyp - 85% of CRC arise from adenomatous polyps - as the tumor grows, the cancer invades and penetrates the muscular mucosa - eventually tumor cells gain access to the regional lymph nodes and vascular system and spread to distant sites - since venous blood leaving the colon and rectum flows through the portal vein and the inferior rectal vein the liver is a COMMON site of metastasis - the cancer spreads from the liver to other sites including lungs, bones and brain - CRC can also spread directly to adjacent structures

- Insidious onset - symptoms often do not appear until disease is advanced - common clinical manfestaions- iron-deficiency anemia, rectal bleeding, abdominal pain, change in bowel habits, intestinal obstruction or perforation - Physical findings may include Early disease: non-specific findings- fatigue weight loss or none at all More advanced disease- abdominal tenderness, palpable abdominal mass, hepatomegaly, ascots - Right sided lesions are more likely to bleed and cause diarrhea - Left sided tumors are usually detected later and could present with bowel obstruction - complications CRC include: obstruction, bleeding, perforation, peritonitis, fistula formation

Insidious onset Symptoms often do not appear until disease is in advanced stages Change in bowel habits Unexplained weight loss Vague abdominal pain Symptoms of cancer in the left side of the colon appear earlier- because annatomically it is the descending that goes to the rectum closest in proximity to the exit- therefore creates most pain and most apparent

Symptoms of cancerous lesions -Rectal bleeding is most common -Alternating constipation and diarrhea -Constipation is actually more common -Change in stool caliber -Narrow, ribbon-like -Sensation of incomplete evacuation -Obstruction

1. Ascending Colon - on the right side - Have right pain and then might be referred to the back- many people think its a kidney stone - Pain, mass change in bowel habits, anemia 2. Transverse colon - Pain - obstruction - change in bowel habits - anemia 3. Descending - pain - change in bowel habits - bright red blood in stool - obstruction - she said anemia is biggest indicator for descending and transverse mostly descending*** *she said Still have anemia on the left side with descending colon, but- other symptoms will prob be worse like pain and blood in stool 4. Rectum - blood in stool - change in bowel habits - rectal discomfort

- descending colon - anemia is biggest indicator for descending colon CRC

-family history of CRC- first degree relative - personal history of IBD - personal history of CRC - family or personal history of familial adenomatous polyposis FAP - Family or personal history of hereditary nonpolyposis colorectal cancer HNPCC syndrome - Obesity - red meat >7 servings a week - cigarette smoking - alcohol >4 drinks a week

-thorough history with close tenting to family history - because symptoms do not become evident until disease is advanced, regular screening is advocated to detect and remove polyps before they become cancerous - beginning at age 50, both men and women at average risk for developing CRC should have screening tests to detect both polyps and cancer based on one tf the test schedules Tests that find polyps AND cancer include - Flexible sigmoidoscopy done ever 5 years - colonoscopy done every 10 years - double contrast barium enema done every 5 years - CT colonography (virtual colonoscopy) done every 5 years Tests that primarily find cancer: - Fecal Occult Blood Test FOBT- done every year - Fecal immunochemical Test FIT- done every year

= colonoscopy - entire colon is examined - only 50% of CRCs are detected by sigmoidoscopy - biopsies can be obtained - polyps can be immediately removed and sent to the lab - people at average risk of CRC should have a colonoscopy every 10 years beginning at age 50, except for African Americans who should have their fist colonoscopy at age 45 Note - less favorable but acceptable screening methods include testing for fecal blood in the stool - FOBT and FIT look for blood in the stool, must be done frequently since tumor bleeding occurs at intervals and may easily be missed if a single test is done - persons at risk should begin screening earlier and more often - first degree relative who developed CRC before age 60 or 2 first degree relatives with CRC should have colonoscopy every 5 years beginning at age 40 or 10 years earlier than the youngest relative developed cancer - those who have one first degree relative who had CRC after age 60 should have the same screening as average risk person*

- additional lab studies are done - CBC to check for anemia - coagulation studies - liver function tests - CT or MRI may be helpful in detecting liver metastases, retroperitoneal and pelvic disease and depth of penetration of the tumor into the bowel wall - liver function tests may be normal even when metastasis has occurred*** - CEA: Carcinoembryonic antigen is a complex glycoprotein sometimes produced by CRC cells may be used to monitor for disease recurrence after surgery or chemo but it is NOT a good screening tool because large number of false positives - better for recurrence

- prognosis and treatment of CRC correlate with pathologic staging of the disease - most commonly used staging system is the tumor, node, metastasis TNM staging - prognosis worsens with greater size and depth of tumor, lymph node involvement and metastasis

Stage 0- cancer has not grown beyond mucosal layer Stage 1- cancer has grown beyond the mucosa into the submucosa, but no lymph nodes are involved Stage 2- cancer has grown beyond the submucosa into the muscle but there is no lump node involvement or metastasis Stage 3- any tumor with lymph node involvement but no metastasis Stage 4- any tumor with lymph node involvement and metastasis

1. Complete resection of the tumor together with adequate margins of a healthy tissue- she said want to go 5cm beyond tumor, you need cancer free areas of the colon to recommend 2. A thorough exploration of the abdomen to determine if the cancer has spread 3. Removal of all lymph nodes that drain the area where the cancer is located 4. Restoration of bowel continuity so that normal bowel function will return 5. Prevention of surgical complications

- some polyps can be removed during colonoscopy, some require surgery - Polypectomy during colonoscopy can be used to resect CRC in situ and is considered successful when the resected margin of the polyp is free of cancer, the cancer is well differentiated and there is no apparent lymphatic or blood vessel involvement

- reduction of colonic bacteria is recommended before surgery to prevent anastomotic leakage of bacteria and to decrease postoperative infection and abscess formation - bowel is typically cleansed with polyethylene glycol lavage solution (MiraLAX, GoLYTELY) and oral antibiotics are given to further decrease amount of colonic and rectal bacteria

- site of cancer dictates site of resection - surgical removal of stage 1 cancer includes removal of the tumor and at least 5cm of intestine on either side of the tumor, plus removal of nearby lymph nodes- the remaining cancer-free ends are sewn back together - laparoscopic surgery is sometimes used in stage I especially those in the left colon - low risk stage II tumors are treated with wide resection and reanastomosis but chemo is used in addition to surgery for high risk stage II tumors - stage III treated with surgery and chemo - once cancer has spread to distant sites (stage 4) surgery is palliative and chemo is directed at controlling the spread- radiation may be used to provide relief

- a temporary colostomy may be done - then later the ends of the colon can be surgically reconnected

- perforation - peritonitis - hemodynamically unstable - later the ends of the colon can be surgical reconnected= goal - if any infection they will not recent anything, just will become necrotic

3 options 1. Local excision 2. Abdominal-perineal Resection ARP with a permanent colostomy 3. Low anterior resection LAR to preserve sphincter function - note she said any time the patient is going into this they have the change of coming out with an ileostomy - surgical decision is based on location, staging, ability to restore normal bowel function and continence - most patients with rectal cancer require APR or LAR - LAR is used more frequently because of the potential for normal control over defecation - when the tumor is not resectable or metastasis is present, palliative surgery is done to control hemorrhage or relieve a malignant bowel obstruction

- both the tumor and the entire rectum are removed - patient has permanent colostomy - perineal wound may be closed around a drain or left open with packing to allow healing by granulation - complications that can occur are delayed wound healing, hemorrhage, persistent perineal sinus tracts, infections, UTI, sexual dysfunction

- to preserve sphincter function - indicated for tumors of the rectosigmoid and mid to upper rectum - if the tumor is far enough from the anal sphincters, the sphincters may be intact - the use of end to end anastomosis staplers has allowed lower (less than 5cm from anus) and more secure anastomoses

- if the rectum is removed and the anal sphincters remain, an alternative reservoir with either a colonic J pouch or coloplasty can be made - colonic J pouch is created by folding the distal colon back on itself and suturing it to form a pouch which replaces the rectum as a reservoir for stool - the patient has a temporary colostomy to allow the J pouch sutures time to heal before stool enters it - Coloplasty is an alternative to the pouch- it is created by slitting the side of a section of colon a short distance proximal to the anus, stretching the colon transversely to make it wider, and then suturing it closed in the new widened position - patients with sphincter-sparing procedure may experience diarrhea, constipation, and innocence even years after the procedure - the colonic J pouch has decreased diarrhea and incontinence problems, but patients may have difficulty evacuating stool

- chemo can be used to shrink the tumor before surgery, as an adjuvant therapy after colon resection and as palliative treatment for nonresectable cancer - adjuvant chemo is recommended for patients with stage III tumors and high risk stage II tumors - curent chemo protocol calls for 5-fluorouracil and foiling acid alone or in combination with oxaliplatin (Eloxatin) -drugs page 988

- may be used postoperatively or as adjuvant to surgery and chemo or as palliative measure for patients with metastatic cancer - as palliative measure its primary objective is to reduce tumor size and provide symptomatic relief

- encourage all people over 50 to have regular CRC screening - ID those high at risk - endoscopic and radiographic procedures can only reveal polyps when the bowel has been adequately prepared and eliminated - provide teaching about eliminating - generally on clear liquid diet 24-48 hours before procedure and is given 4L of oral polyethylene glycol PEG lavage solution the evening before the procedure - drinking 2 L the evening before and 2 L the morning provides better cleansing, especially if scheduled for the afternoon - manufactures have tried to improve taste and palatability - magnesium citrate solution or bisacodyl tablets are sometimes given before PEG to remove bulk of stool so only 2L of PEG are needed - encourage to drink all - stool will be clear or clear yellow liquid when colon is clean

- acute care for patient with colon resection similar to laparotomy - if cancer was resected and ends reanastomsed, bowel function is maintained and routine postop care is appropriate - inform patient about prognosis and future screening - provide support for dealing with the diagnosis of cancer - emotion support changes in body appearance if APR - patients with APR may have an open wound and drains like Jackson-Pratt, Hemovac and a permanent stoma - sterile dressing changes, care of drains consult with patient and wound nurse - reinforce dressings and change them frequently during first several hours postop - assess draininage - draininage is usually serosanguienous******* examine wound and record bleeding, draining odor, use aseptic technique with dressing changes** - if wound is closed or partially closed assess for suture integrity and s/s of inflammation **Patient may expereince phantom rectal sensation because sympathetic nerves responsible fro rectal control are not severed during surgery - sexual dysfunction possible complication of an APR- ejection, ejaculation and orgasm involve different nerve pathways and a dysfunction of one does not mean complete sexual dysfunction

- psychologic support for patient and caregiver - cancer could return - need to know to care for colostomies - even when patients do not have stomas they may experience diarrhea, constipation, incontinence or difficulty passing stool - dietary changes and drugs used to control diarrhea and constipation - patients with sphincter sparing surgery frequently experience diarrhea and incontince of feces and gas often need antidiarrheal drugs or bulking agents - consult with dietitian

- passage of at least 3 loose or liquid stools per day - may be acute or considered choric if lasts more than 4 weeks

- ingestion of infectious organisms is the primary cause of acute diaarhea - viruses cause most cases of infectious diarrhea in US- usually short lived 48 hours - Bacterial infections can be common- E. coli- bloody diarrhea inadequately cooked beef or chicken contaminated with bacteria or in fruits and veggies - some organisms alter secretion or absorption, others impair absorption by destroying cells causing inflammation of the colon - they enter the body in contaminated food or contaminated drinking water - travelers often get diarrhea especially if poor sanitation - infection can be transited from one individual to another via fecal-oral0route - older adults more likely to suffer from life threatening diarrhea - since stomach acid kills ingested pathogens, medications designed to decrease stomach acid increase likelihood of pathogen surviving - healthy colon contains short chain fatty acids and bacteria like e coli- aid in fermentation and provide microbial barrier against pathogenic bacteria - antibiotics kill off the normal flora making individual more susceptible to pathogenic organisms - patients receiving broad spectrum antibiotics (clindamycin, cephalosporoins, fluoroquinolone) are more susceptible to autogenic strains of C. diff

- most serious antibiotic associated diarrhea - probiotics Saccharomyces bollards and Lactobacillus may be helpful in preventing antibiotic induced diarrhea`

- more susceptible to GI infection - those immunocompromised and receiving jejunal enteral nutrition are especially prone to C. find and other food borne infection - Jujenostomy and nasointestinal feedings which bypass the stomach's acid environment do not contain the poorly digestible fiber that is necessary for the survival of normal colonic bacteria

- infectious- drugs and specific food intolerances can cause diarrhea - large amounts of undigested CHO in bowel --> osmotic diarrhea- rapid transit and prevents absorption of fluid and electrolytes - lactose intolerance and certain laxatives produce osmotic diarrhea - bile salts and undigested fats --> excessive fluid secretion in GI tract - diarrhea form relic disease and short bowel syndrome- malabosption of the small intestines

infections that attack upper GI- Norovirus, G. lambda - large volume watery stools, cramping and periumbilical pain - low grade or no fever - often experience n/v before diarrhea begins Infections of colon - Shigella, Salmonella, C. diff produce fever and frequent bloody diarrhea in SMALL volume Leukocytes, blood and mucus may be present in the stool depending - severe diarrhea --> life threatening dehydration, hypokalemia, and acid base imbalances- metabolic acidosis******** - C diff can --> colitis and intestinal perforation

- most resolve quicly - stool cultures only indicated for patients who are very ill, have sig fever, or have had diarrhea longer than 3-5 days -stools examined for blood, mucus, WBC, parasites - can detect toxins in stool - testing for ova and parasites are reserved for patients who have had diarrhea for more than 2 weeks- WBC may be elevated - people with long standing diarrhea may develop anemia

signs of fluid volume deficits

- measure stool, electrolytes, pH and osmolality - stool fat and undigested muscle fibers - some patients with secretory diarrhea have elevated GI hormones

- depends on cause - solutions containing glucose and electrolytes like Pedialyte may be sufficient to replace losses from mild diarrhea - PN administration of fluids, electrolytes, vitamins, minerals is necessary if losses are severe - antidiarrheal agents sometimes given to coat and protect mucous membranes, absorb irritating substances inhibit intestinal transit, - some agents are contraindicated in treatment because prolong exposure to organism - commonly used in IBD- inflammatory bowel disease- because of danger of toxic megacolon - antibiotics rarely used to treat acute diarrhea

- HCI - spores can survive for up to 70 days on objects, including commodes, telephones, thermometers, bedside tables, and floors - can be transmitted patient to patient to workers - control precautions - usually treated by stopping antibiotics and starting patient on metronidazole or vancomycin - metronidazole= first line in mid disease because vancomycin resistant enterococcus - vance used for severe - recurrent C. diff occurs in 20% patients - feces transplantation is under investigation - health persons feces are inserted into GI tract using an enema or NG tube during colonoscopy

- consider all acute diarrhea as infectious until cause is known - wash hands before and after contact with each patient and when handling body fluids of any kind - flush vomit and stool in toilet - viruses and C. diff extremely difficult to kill- alcohol based hand cleansers and ammonia based disinfectants are INEFFECTIVE and even vigorous cleaning with soap and water does not kill everything - provide private room with C. diff infection ensure visitors and HCP wear gloves and gown - infected patients must be given own disposable stethoscopes, thermometers - considera ll objects in room contained ensuring they are disinfect with a 10% solution of household bleach*******

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