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B.
Constant aching pain in the right upper quadrant (RUQ),
11: GASTROINTESTINAL GUIDELINES
right subcostal region, with radiation to the back and right
shoulder.
C.
Nausea and vomiting.
D.
Acalculous cholecystitis may present with fever and sepsis
alone.
OTHER
SIGNS AND SYMPTOMS
A.
Anorexia.
B.
Heartburn.
C.
Upper abdominal fullness.
D.
Biliary colic: sudden onset of severe pain in the epigas-
trium or right hypochondrium that subsides relatively slowly;
tenderness may remain for days.
E.
Fat intolerance.
F.
Fever (low grade).
G.
Mild jaundice (20%).
H.
Complicated disease such as an abscess or perforation;
symptoms include more severe localized persistent pain, tenderness, fever, chills, and leukocytosis.
SUBJECTIVE
A.
Review the onset, location, duration, course, and quality of
DATA
pain.
B.
Use a pain rating scale, such as a 10-point pain scale, with 0
being no pain and 10 being equivalent to the worst pain the client has ever felt. Determine the progression of the pain as well.
C.
Review any alleviating factors, such as antacids, and any
worsening factors, such as deep inspiration.
D.
Review any pain radiating to the jaw, neck, shoulder, or
arm.
E.
Review the onset of pain in relation to the last meal and
foods ingested.
F.
Ask the client about recurrent history of epigastric pain.
G.
Obtain a history and demographic data that may indicate
the risk factors for biliary disease.
H.
Review the date of the client’s last menstrual period, and if
pregnant establish gestational age.
PHYSICAL
A.
The absence of physical ndings does not rule out the
EXAMINATION
diagnosis of cholecystitis.
B.
Check temperature, pulse (tachycardia), respirations, and
blood pressure.
C.
Inspect:
1.
Observe the client’s general appearance, facial expres-
sions, gait, skin color (15% have jaundice) and turgor, and
grimace during examination. Overall appearance is generally unremarkable between attacks; ill appearance occurs
during an acute attack.
D.
Auscultate:
1.
Heart.
2.
Lung elds.
3.
Abdomen for bowel sounds in all four quadrants.
E.
Percuss:
1.
Percuss the abdomen.
F.
Palpate:
1.
Palpate the abdomen; check for tenderness in the
RUQ, especially with inspiration; assess for guarding and
rebound tenderness.
2.
Check Murphy sign. Ask the client to inspire deeply
while the examiner palpates the area of the gallbladder
fossa just beneath the liver edge. A positive Murphy sign
is an inspiratory pause secondary to extreme tenderness
during palpation.
DIAGNOSTIC
A.
Laboratory tests:
1.
2.
3.
TESTS
Amylase: normal in classic cholecystitis.
Complete blood count with differential: leukocytosis.
Alkaline phosphate: normal in classic cholecystitis;
elevated in 25% of clients with cholecystitis.
4.
Bilirubin: normal to mildly elevated in classic
cholecystitis.
5.
Aspartate transaminase: slightly elevated to normal.
6.
Alanine transaminase: slightly elevated to normal.
7.
Urinalysis to rule out pyelonephritis and renal calculi.
8.
Pregnancy test if childbearing age.
9.
Stool guaiac test for occult blood to rule out bleeding.
B.
Radiography:
1.
Ultrasonography: sudy of choice; can often establish
the diagnosis. Positive ndings include the presence of
stones, gallbladder wall thickening, or enlargement and
uid. Sonographic Murphy sign is dened as an inspiratory pause with a deep breath while the gallbladder is
being insonated.
2.
Cholescintigraphy (hepatobiliary iminodiacetic acid
[HIDA]) scan is indicated if the diagnosis is uncertain after
an ultrasound. However, it is not recommended in critically ill clients, as the test takes hours to perform and a
delay in therapy can be potentially fatal.
3.
Magnetic resonance cholangiopancreatography
(MRCP): noninvasive technique to evaluate intrahepatic
or extrahepatic bile ducts.
4.
CT scan: can identify extrabiliary disorders and com-
plications of acute cholecystitis.
5.
Endoscopic retrograde cholangiopancreatography
(ERCP): useful in clients with signs of common bile duct
obstruction.
6.
Chest radiography to rule out pneumonia.
C.
EKG to rule out myocardial infarction (MI).
DIFFERENTIAL
A.
Acute cholecystitis.
B.
Biliary colic.
C.
Acute pancreatitis.
D.
Appendicitis.
E.
Peptic ulcer disease/perforation.
F.
Acute hepatitis, hepatic abscess.
G.
Pneumonia or pleurisy.
H.
MI.
I.
Renal calculi.
J.
Gastroesophageal reux disease (GERD).
K.
Pregnancy.
L.
Pyelonephritis.
DIAGNOSES
PLAN
A.
General interventions:
1.
Clients with a single episode of biliary colic are reason-
able candidates for expectant management as long as they
continue to be free of recurrent pain.
B.
Client teaching: See Client Teaching Guide for this chapter,
“Cholecystitis.”
1.
No activity restriction is required.
2.
Treatment depends on acuteness of the attack. If pain
continues to worsen, have the client contact their healthcare provider. Hospitalization and/or surgery may be
required depending on the severity of the attack.
3.
Counsel the client to avoid fatty foods.
4.
Encourage the client to avoid fasting and starvation
diets, which make the bile even more lithogenic.
C.
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Pharmaceutical therapy:
1.
Acetaminophen (Tylenol) may be used as needed for
pain.
2.
Anticholinergics are not helpful.
3.
Oral bile acid therapy decreases the amount of choles-
terol produced by the liver and absorbed by the intestines.
a.
Ursodiol (Actigall):
i.
Dissolution of stones: 8 to 10mg/kg/d in two
or three divided doses. Many months of treatment
may be required for dissolution of gallstones.
ii.
Ursodiol (Urso) 250mg tablets; also available as
Urso Forte 500mg tablets.
4.
Antibiotics: As per the Infectious Diseases Society of
America (IDSA):
a.
Cefazolin, cefuroxime, or ceftriaxone: for cli-
ents with community-acquired acute cholecystitis of
mild-to-moderate severity.
b.
Imipenem–cilastatin, meropenem, doripenem,
piperacillin–tazobactam, ciprooxacin plus metronidazole, levooxacin plus metronidazole, or cefepime plus
metronidazole: for clients with community-acquired
acute cholecystitis of severe physiologic disturbance,
advanced age, or immunocompromised state.
c.
Imipenem–cilastatin, meropenem, doripenem,
piperacillin–tazobactam, ciprooxacin plus metronidazole, levooxacin plus metronidazole, or cefepime
plus metronidazole, with vancomycin added to each
regimen: for clients with healthcare-associated biliary
infection of any severity.
5.
Antiemetics for nausea and vomiting.
6.
Drug dissolution therapy with ursodeoxycholic acid
and extracorporeal shock-wave lithotripsy have lower
cure rates.
D.
Surgical management:
1.
Cholecystectomy may be recommended for symp-
tomatic clients. The standard of care is the laparoscopic cholecystectomy. The conversion rate from a
laparoscopic procedure to an open surgical procedure is
approximately 5%.
FOLLOW-UP
A.
See the client at the next pain attack to reevaluate.
B.
Surgical follow-up in 2 weeks.
CONSULTATION/REFERRAL
A.
For an acute attack, consult a surgeon for evaluation for
surgery.
B.
Refer the client for elective cholecystectomy when they
have documented gallstones and recurrent biliary colic or a history of complication of gallstone disease such as pancreatitis.
C.
Refer the client to a gastroenterologist for consideration of
ERCP.
INDIVIDUAL
A.
Pregnancy:
1.
CONSIDERATIONS
The RUQ or epigastric pain in pregnancy differential
includes preeclampsia, pancreatitis, hemolysis, elevated
liver enzymes, low platelet count (HELLP) syndrome,
acute fatty liver, abruptio placentae, uterine rupture,
intra-amniotic infection, and appendicitis.
2.
In the absence of pancreatitis, maternal mortality
should be rare and fetal loss is generally estimated to be
no more than 5%. However, if secondary pancreatitis is
COLIC
339
present, maternal mortality is 15% and fetal loss is reported
to be as high as 60%.
B.
Pediatrics:
1.
Clients with sickle cell disease are at higher risk for
developing cholecystitis.
2.
Infants with cholecystitis may present with irritability,
jaundice, and acholic (pale white) stools.
3.
The most common complication of gallstones in chil-
dren is pancreatitis.
C.
Geriatrics:
1.
Signs and symptoms may be nonspecic and vague.
2.
Localized tenderness may be the only presenting sign.
3.
The Murphy sign response may be diminished in the
elderly.
4.
Early cholecystectomy is advocated for elderly clients
with gallstone disease. The most important risk factor for
postoperative morbidity and mortality is advanced age.
5.
Biliary sludge and/or gallstones are likely to form in
one in ve children with hemolytic anemia before their
adolescent years.
BIBLIOGRAPHY
Afdhal, N. H. (2019, March 11). Acalculous cholecystitis: Clinical manifes-
tations, diagnosis, and management. UpToDate. https://www.uptoda
te.com/contents/acalculous-cholecystitis-clinical-manifestationsdiagnosis-and-management#H231456978
Prescriber’s Digital Reference. (2019). Ursodiol-drug summary. https://www.
pdr.net/drug-summary/Actigall-ursodiol-1231
Vege, S. S. (2019, January 9). Etiology of acute pancreatitis. UpToDate.
https://www.uptodate.com/contents/etiology-of-acute-pancreatitis
COLIC
DEFINITION
A.
Colic is a benign disorder characterized by abdominal
spasms and rigidity that result in abdominal pain. Infants
with colic exhibit persistent, unexplained, and inconsolable
crying, lasting more than 3 hours a day, occurring more than
3 days in a week for 3 weeks in an otherwise healthy infant
less than 3 months of age. The infant is in good health, eats
well, and gains weight appropriately, despite the daily crying
episodes. Colic is self-limited.
INCIDENCE
A.
Between 8% and 40% of all infants exhibit colic, regard-
less of ethnicity, gender, gestational age, breastfed versus
bottle-fed, or socioeconomic status.
PATHOGENESIS
A.
Research has never conclusively identied a cause for colic,
and many interventions are based on hypothesized causes,
such as immature gastrointestinal (GI) function, milk allergy
to casein or whey, and maternal anxiety. Exposure to cigarette
smoke may be linked to colic. There has been a causal relationship between colic and family stress.
PREDISPOSING
A.
Age: 2 weeks to 4 months; usually resolves by 6 months of
age.
B.
Generally colic is equally frequent in males and females.
C.
First in birth order.
D.
Fruit juice intolerance (sorbitol-containing fruit juices).
E.
Faulty feeding techniques: underfeeding, overfeeding, or
infrequent burping and swallowing air.
FACTORS
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11: GASTROINTESTINAL GUIDELINES
COMMON
A.
COMPLAINTS
Crying characteristics:
1.
Intense crying: louder, higher, and more variable in
pitch.
2.
The cry may sound like the baby is in pain or is scream-
ing rather than crying.
3.
Inconsolable.
OTHER
SIGNS AND SYMPTOMS
A.
Hands clenched.
B.
Abdominal distention.
C.
Legs exed over abdomen.
D.
Short sleep cycles.
E.
Flatus.
F.
Fussiness.
G.
No disease process found on examination.
H.
Red ags include distended abdomen, fever, and lethargy.
SUBJECTIVE
A.
Review when the crying occurs and how long it lasts.
DATA
What techniques help?
B.
Review basic infant needs with caregivers, such as deter-
mining whether the infant is hungry or wet, has air bubbles,
or is in an uncomfortable position.
C.
Review feeding methods, technique, and burping. Crying
that occurs directly after feeding may be associated with swallowing too much air or gastroesophageal reux.
D.
If the infant is breastfed, review the maternal diet for
offending foods, including chocolate, pizza, spicy foods, cabbage, and so forth.
E.
If the infant is breastfed, review prescribed maternal drugs
and any over-the-counter medications that they are taking,
such as laxatives.
F.
If the infant is bottle-fed, review preparation of formula
and thetype of formula.
G.
Rule out the early introduction of solid foods.
H.
Review any history of fever and high-pitched or shrill cry.
I.
Have the caregiver describe the color, frequency, and soft-
ness of stools.
J.
Review secondhand smoke exposure: There is an associa-
tion between maternal smoking and colic.
PHYSICAL
A.
Check temperature, pulse, respirations, blood pressure,
EXAMINATION
and weight.
1.
Children: Plot growth parameters including length,
head circumference, and weight. Note signs of failure to
thrive (FTT). Failure to gain approximately 1 oz/d may
indicate FTT.
B.
Inspect:
1.
Evaluate the skin for signs of abuse.
2.
Check the fontanelles for bulge.
3.
Conduct ear, eye, nose, and throat examinations.
4.
Evaluate the skin and mucosa for signs of dehy dration.
5.
Evaluate the perineum for diaper rash, meatal ulcer, or
inguinal hernia.
C.
Auscultate:
1.
Abdomen.
2.
Heart and lungs.
D.
Percuss:
1.
Abdomen.
E.
Palpate:
1.
Palpate the abdomen for tenderness, masses, and
distention.
2.
Feel the anterior and posterior fontanelles.
3.
Perform a testicular examination to evaluate torsion.
DIAGNOSTIC
A.
Colic is a diagnosis of exclusion and must be differentiated
TESTS
from identiable causes of prolonged crying.
B.
Laboratory tests and radiographic examination are not
required if the infant is gaining weight and has a normal physical examination.
C.
Consider urinalysis.
D.
Check the infant’s stool for occult blood to rule out cow’s
milk allergy.
DIFFERENTIAL
A.
Colic.
B.
Infection.
C.
Obstruction.
D.
Injury.
E.
Abuse.
F.
FTT.
G.
Gastroesophageal reux disease.
H.
Intussusception.
I.
Meningitis.
J.
Otitis media.
K.
Protein intolerance.
L.
Testicular torsion.
M.
Strangulated inguinal hernia.
DIAGNOSES
PLAN
A.
General interventions:
1.
Reassure the family that the baby has no evidence of
infant developmental problems and the problem is not
related to poor parenting skills.
2.
Reassure the family that colic does resolve over time.
3.
Encourage parents to take time away from the infant
to rest and recoup the energy needed to deal with the
demands of a crying baby.
4.
Empathize with parental frustration and provide cop-
ing techniques.
Physical
abuse of the infant with colic may occur when crying is pro-
longed and parents have inadequate resources to cope.
5.
Consider a hypoallergenic diet (e.g., protein
hydrolysate formula such as Alimentum, Nutramigen, or
Pregestimil). The literature does not support the use of
ber-enriched formulas.
B.
Client teaching: See Client Teaching Guide for this chapter,
“Colic: Ways to Soothe a Fussy Baby.”
1.
Encourage parents and caregivers to keep a diary on
crying and fussing spells for review.
2.
Review feeding and burping techniques, making sure
the baby is not overfed or underfed.
3.
Teach caregivers to assess the child for signs of emer-
gent abdominal problems such as fever, pallor, sweating,
vomiting, diarrhea, and a rigid and tender abdomen.
C.
Pharmaceutical therapy:
1.
Simethicone has little therapeutic benet versus a
placebo for treating colic according to randomized controlled trials.
2.
Antispasmodics have adverse effects, including apnea,
seizures, and coma. Dicyclomine is contraindicated in
infants younger than 6 months of age and is not considered for the indication of colic by the manufacturer.
3.
Lactase is not a therapeutic option for colic.
4.
For breastfed infants, consider ve drops of Lactobacillus
reuteri DSM 17938 per day. Evidence does not support
other forms of probiotics or prebiotics.
5.
Sedatives should not be used for treatment of colic.
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6.
Herbal remedies are common in many cultures, but
few herbal products have been evaluated for colic.
D.
Dietary management:
1.
Dietary changes such as eliminating cow’s milk pro-
teins are indicated only in cases of suspected intolerance
to protein (e.g., positive family history, eczema, onset after
the rst month, association with other GI symptoms such
as vomiting or diarrhea).
2.
Use of soy-based formula is not recommended because
many infants who are allergic to cow’s milk protein also
develop an intolerance to soy protein.
3.
For breastfeeding mothers, suggest a period of elimina-
tion of allergic foods (e.g., dairy, nuts, soy, citrus) to evaluate the baby’s response.
4.
For formula-fed infants, consider hydrolyzed formula.
5.
Educate caregivers to avoid the use of homegrown
mint teas for fussy babies. Fatalities have been reported
secondary to ingestion of the pennyroyal form of mint,
which produces a toxic oil.
FOLLOW-UP
A.
Reevaluate the child periodically to provide support and
assess for other problems.
B.
Review signs of emergent abdominal problems such as
fever, pallor, sweating, vomiting, diarrhea, and rigid and tender abdomen.
COLORECTAL CANCER SCREENING
341
CONSULTATION/REFERRAL
A.
Refer to a behavioral/developmental pediatrician or men-
tal health provider as needed.
B.
Consider a home-based nursing consultation.
C.
Refer the breastfeeding mother for an observational
feeding.
BIBLIOGRAPHY
Turner, T. L., & Palamountain, S. (2022, May). Patient education: Colic (exces-
sive crying) in infants (beyond the basics). UpToDate https://www.
uptodate.com/contents/colic-excessive-crying-in-infants-beyondthe-basics
COLORECTAL
CANCER SCREENING
DEFINITION
A. Screening
for colorectal cancer (CRC) has increased
early detection and the ability to engage in early intervention of premalignant localized cancer. There are multiple screening guidelines; the U.S. Preventive Services Task
Force’s (USPSTF) recommendations are presented in this
review (Table 11.2). Screening is done for males and females
between the ages of 45 and 75 years. There are two categories
of screening:
1. Stool-based testing.
2. Endoscopic and radiologic testing.
TABLE
11.2 CRC SCREENING RECOMMENDATIONS FOR ADULTS AT AVERAGE RISK
U.S. Preventive Task
Force—2021
American Cancer Society—2018 U.S. MSTFa on CRC—2018
Start screening at age 45. Start screening at age 45. Start screening at age 45.
Stop screening at 75. For adults with average CRC risk,
in good health, and with a life
expectancy of more than 10 years,
screening should continue through
age 75 years.
Ages for screening
Highly sensitive
The decision to be screened after
75–85 should be made on an
individual basis taking into account
the client’s overall health and
screening history.
Screening after age 85 is not
recommended.
Annual Annual No recommendation
The decision to be screened for clients
aged 76–85 years should be
individualized to client preference,
life expectancy, health status, and
history of screening.
Screening after 85 is not
recommended.
gFOBT
Starting screening at the age of 45
years may improve early detection
and prevention of CRC.
years of life expectancy.
Persons without prior screening should
be considered for screening up to
age 85, depending on age and
comorbidities.
Colonoscopy and FIT are
recommended as the cornerstone
of screening regardless of how
screening is offered.
Highly sensitive FIT Annual Annual Annual
FIT fecal DNA Every 1 or 3 years
b
No recommendation Every 3 years
(continued)
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11: GASTROINTESTINAL GUIDELINES
TABLE 11.2 CRC SCREENING RECOMMENDATIONS FOR ADULTS AT AVERAGE RISK (CONTINUED)
U.S. Preventive Task
Force—2021
American Cancer Society—2018 U.S. MSTFa on CRC—2018
MT-sDNA test Every 1–3 years Every 3 years No recommendation
FSIG
FSIG and FIT DNA
Every 5 years OR the FSIG and FIT
DNA recommendation
FSIG every 10 years plus FIT every
year
Colonoscopy Every 10 years Every 10 years Every 10 years
CT colonography
Every 5 years Every 5 years Every 5 years
Every 5 years Every 5–10 years
No recommendation No recommendation
c
(virtual
colonoscopy)
a
MSTF represents the American College of Gastroenterology, the American Gastroenterological Association, and the American Society for Gastrointestinal Endoscopy.
b
FIT DNA testing suggested by manufacturer.
c
Colonoscopy offered first; FIT should be offered to clients who decline colonoscopy.
CRC, colorectal cancer; FIT, fecal immunochemical test; FSIG, flexible sigmoidoscopy; gFOBT, guaiac-based fecal occult blood test; MT-sDNA, multitargeted stool DNA;
MTSF, Multi-Society Task Force.
Source: Reproduced from Cash, J. C., & Glass, C. A. (2019). Adult-gerontology practice guidelines (2nd ed.). New York, NY: Springer Publishing Company.
B.
INCIDENCE
A.
In the United States, CRC is the second leading cause of
cancer-related death in males and females.
B.
Americans have a 4.4% lifetime risk of CRC.
C.
CRC is infrequent before age 40 years. It is most frequently
diagnosed among adults aged 65 to 74 years. Consider screening in older clients if symptoms are present and life expectancy is greater than 10 years.
D.
Approximately 90% of all CRC cases occur after age
50 years.
E.
Up to 20% of CRC casesin the United States are associated
with smoking.
F.
Obesity is associated with colon cancer but not an increase
in rectal cancer. Abdominal obesity is a stronger risk factor
than truncal obesity or body mass index (BMI).
PATHOGENESIS
A.
The usual pathogenesis is an adenomatous polyp that
grows slowly, followed by dysplasia and nally cancerous
cells.
PREDISPOSING
A.
Age: 45 years and older.
B.
African American: Screening is recommended at age
FACTORS
40 years. Mortality from CRC is approximately 20% higher in
African Americans compared with Whites.
C.
Sex: Risk is higher in males (4.49%) than in females (4.15%).
D.
Inammatory bowel disease (IBD): Crohn’s disease (CD)
and ulcerative colitis (UC).
E.
Family history/genetic:
1.
Familial adenomatous polyposis (FAP).
2.
Nonpolyposis CRC (Lynch syndrome).
F.
Smoking.
G.
Alcohol.
H.
Obesity.
I.
Diet high in red meat and fats.
J.
Diabetes mellitus.
Routine screening after the age of 45 years. See guidelines
for routine colonoscopy screening in Table 11.2.
SUBJECTIVE
A.
Review the client’s age and risk factors to discuss screen-
DATA
ing for CRC.
B.
Review family history of CRC.
C.
Review smoking and alcohol history.
D.
Review the client’s diet, evaluating intake of red meat,
processed meats, and lack of grains, fruits, and vegetables.
E.
Review all medications currently being taken, including
over-the-counter medications and herbal products.
PHYSICAL
A.
Examinations are not required for discussion of colorectal
EXAMINATION
screening testing.
B.
A physical examination should be performed and vital
signs taken as indicated for other presenting complaints.
DIAGNOSTIC
A.
See Table 11.3 for frequency of tests.
B.
Stool-based testing:
1.
2.
TESTS
Guaiac-based fecal occult blood test (FOBT).
Fecal immunochemical test (FIT) is replacing FOBT
as the preferred cancer detection test.
3.
FIT DNA panel.
4.
Multitarget stool DNA testing (MT-sDNA) combines
fecal markers for hemoglobin and DNA mutation and
methylation.
5.
Stool-based screening tests are NOT as effective as
colonoscopy in accurately detecting precancerous polyps.
C.
Endoscopic and radiologic:
1.
Flexible sigmoidoscopy.
2.
Colonoscopy: This is the most highly recommended
screening test according to U.S. Multi-Society Task Force
on Colorectal Cancer (MSTF).
3.
Double-contrast barium enema (DCBE): The
American College of Gastroenterology recommends the
DCBE as a screening test; however, it has limited effec-
COMMON
A.
COMPLAINTS
Asymptomatic.
tiveness for polyp detection.
4.
CT colonography (CTC) every 5 years.
COLORECTAL CANCER SCREENING
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TABLE
11.3 SCREENING TESTS AT A GLANCE BASED ON USPSTF COLORECTAL CANCER SCREENING
Name Preparation What Happens? Frequency
343
High-sensitivity FOBT or
stool test; or FIT
Note: There are two types
of FOBT: One uses the
chemical guaiac to detect
blood. The other—a FIT—
uses antibodies to detect
blood in the stool.
Ask your doctor for a
high-sensitivity FOBT or
FIT.
The onetime FOBT done by
the doctor in the doctor’s
office is not appropriate
as a screening test for
colorectal cancer.
FIT-DNA is an emerging
screening strategy. It is a
multitargeted stool DNA
test combined with FIT
testing.
Flexible sigmoidoscopy (flex
sig)
Note: This is sometimes
done in combination with
high-sensitivity FOBT.
Your doctor may recommend
that you follow a special diet
before taking the FOBT.
Your doctor will tell you what
foods you can and cannot eat
before the test. The evening
before the test, you use a
strong laxative and/or enema
to clean out the colon.
You receive a test kit from your
healthcare provider. At home, you
use a stick or brush to obtain a
small amount of stool. You may be
asked to do this for several bowel
movements in a row. You return
the test kit to the doctor or a lab,
where stool samples are checked
for blood.
During the test, the doctor puts a
short, thin, flexible, lighted tube
into the rectum. This tube allows
the doctor to check for polyps or
cancer inside the rectum and lower
third of the colon.
This test should be done every year.
(If anything unusual is found, your
doctor will recommend a follow-up
colonoscopy.)
The FIT-DNA test should be done every
year or once in 3 years (suggested
by the manufacturer).
This test should be done every
5 years. When it is done in
combination with high-sensitivity
FIT, the FIT should be done every
year and flex sig every 10 years.
(If anything unusual is found, your
doctor will recommend a follow-up
colonoscopy.)
Colonoscopy Before this test, your doctor
will tell you what foods you
Note: Colonoscopy is also
used as a follow-up test if
anything unusual is found
during one of the other
screening tests.
can and cannot eat. You use
a strong laxative to clean
out the colon. Some doctors
recommend that you also use
an enema. Make sure you
arrange for a ride back home
as you will not be allowed to
drive.
FIT,
fecal immunochemical test; FOBT, fecal occult blood test; USPSTF, U.S. Preventive Services Task Force.
Source:
Adapted from U.S. Preventive Services Task Force. (2016, June). Final recommendation statement: Colorectal cancer screening. www.uspreventiveservicestaskforce.
org/Page/Document/RecommendationStatementFinal/colorectal-cancer-screening2#tab.
DIFFERENTIAL
A.
None related to screening.
DIAGNOSES
You will receive medication during
this test to make you more
comfortable. This test is similar to
flex sig, except the doctor uses a
longer, thin, flexible, lighted tube to
check for polyps or cancer inside
the rectum and the entire colon.
During the test, the doctor can find
and remove most polyps and some
cancers.
FOLLOW-UP
A.
Follow-up and consultations are determined by the cli-
This test should be done every 10
years. If polyps or cancers are
found during the test, you will need
more frequent colonoscopies in the
future.
ent’s needs, severity, and whether complications are present.
B.
A.
Client teaching:
1.
Educate the client about modifying controllable risk
factors with diet, exercise, and smoking cessation.
2.
Discuss the procedures and the preparation needed for
each test.
B.
Pharmaceutical therapy:
1.
Bowel prep depends on the test, the client’s age, and
other comorbidities.
Clients with classic FAP (>100 adenomas) should be
advised to have genetic counseling.
C.
Nonsteroidal anti-inammatory drugs (NSAIDs) have
been associated with a decrease in the risk of developing
CRC. There is insufcient evidence to recommend the use of
NSAIDs as a prevention strategy.
D.
The USPSTF has made a recommendation on aspirin use
for primary prevention of cardiovascular disease and CRC in
average-risk adults (www.uspreventiveservicestaskforce.org).
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11: GASTROINTESTINAL GUIDELINES
CONSULTATION/REFERRAL
A.
Referral to a gastroenterologist and/or surgeon as
indicated.
INDIVIDUAL
A.
Geriatrics:
1.
CONSIDERATIONS
The benet of early detection of and intervention for
CRC declines after age 75 years. Screening for adults aged
76 to 85 years should be made on an individual basis (see
Table 11.2), taking into account the client’s overall health
and screening history.
2.
Medicare Part B covers several colorectal screening
tests:
a.
Medicare covers a screening barium enema when
used instead of a exible sigmoidoscopy or colonoscopy once every 48 months for clients 50 years or older
and once every 24 months if at high risk.
b.
Screening colonoscopy is covered every 24 months
if at high risk for CRC. If not at high risk, Medicare
covers the colonoscopy once every 120 months, or
48 months after a previous exible sigmoidoscopy.
3.
FOBT is covered by Medicare once every 12 months for
clients age 50 years or older.
4.
Flexible sigmoidoscopy is covered by Medicare every
48 months for most people older than 50 years. If not at
high risk, Medicare covers exible sigmoidoscopy every
120 months after a previous screening colonoscopy.
5.
MT-sDNA at-home test is covered once every 3 years
for people who meet all of the following criteria:
a.
Between ages 50 and 85 years.
b.
No signs or symptoms of colorectal disease, includ-
ing, but not limited to, lower gastrointestinal pain,
blood in stool, positive guaiac FOBT, or FIT.
c.
Average risk for developing CRC:
i.
No personal history of adenomatous polyps,
CRC, or IBD, including CD and UC.
ii.
No family history of CRC or adenomatous pol-
yps, FAP, or hereditary nonpolyposis CRC.
RESOURCES
Centers
for Disease Control and Prevention—Screening Tests at-a-Glance
includes the 2008 recommendations on screening for CRC from the
USPTF website: www.cdc.gov/cancer/colorectal/pdf/SFL_inserts_
screening.pdf
Medicare.gov,
Your Medicare coverage—colorectal cancer screenings:
www.medicare.gov/coverage/screening-colono -scopies
National
Cancer Institutes, National Institutes of Health—Colon and rec-
tal cancer: www.cancer.gov/cancertopics/types/colon-and-rectal
National
Cancer Institute, National Institutes of Health—Rectal cancer
treatment for professionals (PDQ): www.cancer.gov
National
Cancer Institutes, National Institutes of Health—Tests to
detect colorectal cancer and polyps: www.cancer.gov/cancertopics/
factsheet/detection/colorectal-screening
National
Comprehensive Cancer Network: www.nccn.org
BIBLIOGRAPHY
American Cancer Society. (2019). Key statistics for colorectal cancer. https://
www.cancer.org/cancer/colon-rectal-cancer/about/key-statistics.
html
Centers for Disease Control and Prevention. (n.d). Screening tests at-a-
glance. https://www.cdc.gov/cancer/colorectal/pdf/SFL_inserts_
screening.pdf
Doubeni, C. (2021, Oct 21). Screening for colorectal cancer: Strategies in
patients at average risk. UpToDate. https://www.uptodate.com/
contents/screening-for-colorectal-cancer-strategies-in-patients-ataverage-risk#H742539081
Medicare.gov. (n.d). Your Medicare coverage: Colorectal cancer screening.
www.medicare.gov/coverage/colorectal-cancer-screenings.html
Macrae, F.A. (2021, September 22). Colorectal cancer: Epidemiology, risk
factors, and protective factors. https://www.uptodate.com/contents/
colorectal-cancer-epidemiology-risk-factors-and-protective-factors
U.S. Preventive Service Task Force. (2021, May). Final Recommendation
statement: Colorectal cancer: screening. https://www.uspreventiveserv
icestaskforce.org/uspstf/recommendation/colorectal-cancer-screeni
ng#fullrecommendationstart
CONSTIPATION
DEFINITION
A. Constipation
stools and a sensation of incomplete evacuation or straining. Constipation may also refer to a decrease in the volume
or weight of stool, and the need for enemas, suppositories,
or laxatives to maintain bowel regularity. Constipation is a
symptom, not a disease. The lower limit of normal stool frequency is three bowel movements (BMs) a week. The Rome
consensus criterion denes constipation as two or fewer stools
weekly, lumpy/hard stools, straining, sensation of incomplete
evacuation/obstruction or blockage, and/or the need for digital removal of stool.
B. Classication of constipation:
1. Normal-transit constipation (most common).
2. Functional constipation (slow transit).
3. Irritable bowel syndrome (IBS; constipation dominant).
4. Outlet obstruction (sudden onset).
INCIDENCE
A.
The incidence of constipation is unknown due to fre-
quent self-treatment. Constipation is commonly self-reported.
Constipation occurs in more than 50% of clients with colorectal cancer (CRC); it may be an early symptom of rectal cancer
or a symptom of advanced disease in colon cancer.
PATHOGENESIS
A.
Constipation can be caused by an alteration of the lling of
the rectum by colonic transportation and/or reex defecation
of stool.
B.
Lack of exercise decreases propulsion of bowel contents.
C.
During pregnancy, progesterone has a relaxing effect on
the muscles of the gastrointestinal (GI) tract and causes a
decrease in peristalsis. The compression of the intestines by
the enlarging uterus causes constipation during pregnancy.
D.
Habitual use of laxatives is associated with impaired motor
activity and has the potential of producing hypokalemia.
E.
Severe hypokalemia can produce a generalized ileus and
is most often seen in clients who take diuretics.
F.
Psychiatric disease and psychosocial distress have impor-
tant roles. The exact mechanisms by which emotional difculties lead to constipation remain unclear, but their contribution
is widely recognized.
G.
Drugs (Table 11.4).
PREDISPOSING
A.
Insufcient nutrition:
1.
Low-ber diet.
2.
Low uid intake.
B.
Neurologic causes:
1.
Spinal cord injury.
2.
Parkinson disease.
3.
Multiple sclerosis.
4.
Aganglionosis (Hirschsprung disease [HD]).
5.
Sacral nerve trauma/tumor.
C.
Sedentary lifestyle.
is infrequent and difcult defecation of hard
FACTORS
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11.4 DRUGS/DRUG CLASSIFICATIONS
THAT CAUSE AND INCREASE CONSTIPATION
Anticholinergics (Atropine,
Antidepressants, Neuroleptics,
Antiparkinsonian drugs) Opiates
Antipsychotics Cholestyramine (binds
bile salts)
Anticonvulsants Antacids (aluminum
hydroxide and
calcium carbonate)
Antihistamines Iron supplements
Antihypertensives (calcium channel
NSAIDs
blockers, clonidine, hydralazine, MAOIs,
methyldopa)
Diuretics Ganglionic blockers
MAOIs,
monoamine oxidase inhibitors; NSAIDs, nonsteroidal anti-inflammatory
drugs.
D.
Laxative abuse.
E.
Travel.
F.
Ignoring urge to defecate.
G.
Drug use: individual medications and polypharmacy.
H.
Pregnancy, especially third trimester.
I.
Psychosocial problems:
1.
Depression.
2.
Sexual abuse.
3.
Unusual attitudes to food and bowel function.
J.
Extremes of ages: infants and geriatrics.
K.
Hypothyroidism.
L.
CRC.
M.
IBS.
N.
Pelvic oor disorders:
1.
Impaired function of the pelvic oor and/or external
sphincter.
2.
Pelvic oor obstruction.
3.
Rectal prolapse.
4.
Enterocele and/or rectocele.
5.
Rectal intussusception.
COMMON
A.
B.
C.
D.
OTHER
A.
B.
C.
D.
E.
POTENTIAL
A.
COMPLAINTS
Hard, infrequent stools.
Straining.
Inability to defecate when desired.
Need for digital manipulation to facilitate evacuation.
SIGNS AND SYMPTOMS
Hard, pebbly, rocklike stools.
Painful defecation.
Abdominal pain.
Weight loss.
Blood in stools.
COMPLICATIONS
A rectal prolapse of the mucosa is pink and looks like a
doughnut or rosette. Complete prolapse involving the muscular wall is larger and red, and has circular folds.
SUBJECTIVE
A.
Review the onset, duration, and course of symptoms.
1.
DATA
Is constipation a chronic or acute problem?
CONSTIPATION
2.
If there has been a change in bowel habits, was it grad-
ual or sudden?
3.
What feature does the client rate as most distressing?
B.
Review bowel habits.
1.
Does the client have a regular time for defecation?
2.
Review size, color, consistency, and frequency of stools.
Has there been a change in the caliber of stools?
3.
Is there any blood?
4.
Are there any periods of diarrhea?
5.
How often are laxatives being used and at what doses?
6.
Are suppositories and enemas also required?
7.
Does the client have the urge to defecate?
8.
Does the client have a sensation of incomplete
evacuation?
9.
Does the client need to digitally remove stool?
10.
Does the client have fecal incontinence?
C.
Review the client’s daily diet and uid intake. Has there
been any dietary change?
D.
Review the client’s medication history: prescription and
over-the-counterdrugs (refer to Table 11.4)
E.
Review the client’s daily physical activity.
F.
Review the client’s psychosocial history of stress, depres-
sion, anxiety, and coping mechanisms.
G.
Review the client’s other health problems, such as diabe-
tes, depression, hypothyroidism, and hypercalcemia.
H.
Review family history of constipation and CRC.
I.
Review surgical history.
PHYSICAL
A.
Check pulse, respirations, blood pressure, and weight.
EXAMINATION
Check temperature if indicated.
B.
Inspect:
1.
General overall assessment of nutritional status.
2.
Examine the skin, especially the rectum, for pallor and
signs of dehydration and hypothyroidism.
3.
Evaluate for presence of hernias.
4.
Inspect the anus, including the position, anal wink,
prolapse, presence of excoriation, presence of perianal erythema, hemorrhoids, ssures, and skin tags.
5.
Examine the lower back to rule out spinal lesions: hairy
or hyperpigmented patches, gluteal fold asymmetry, cutaneous dimples, sinus tracts, and lipomas.
C.
Auscultate:
1.
Abdomen: four abdominal quadrants for bowel
sounds. Bowel sounds may be high pitched or absent.
D.
Percuss:
1.
Abdomen: Constipation will present changes from
tympanic to dull.
E.
Palpate:
1.
Abdomen for masses, tenderness, distention, and fecal
mass.
F.
Digital rectal examination:
1.
Examine the rectum for an anorectal mass, stricture,
hemorrhoids, ssures, stula, prolapse, inammation, and
anal warts.
2.
Evaluate for impaction, hard stool in theampulla.
3.
Perform an anal reex test by a light pinprick or
scratch.
4.
Evaluate sphincter tone:
a.
Disordered innervation of the anus is indicated
by nding that the anal canal opens wide when the
puborectalis muscle is pulled posteriorly.
b.
Evaluate the resting tone of the sphincter and
squeezing effort.
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11: GASTROINTESTINAL GUIDELINES
c.
Instruct the client to “expel the examination nger”
to evaluate the force of expulsion.
d.
Have the client do a Valsalva maneuver to diagnose
a rectocele, prolapse, pelvic oor descent, or puborectalis dysfunction.
e.
In females, the vagina should also be evaluated for
rectocele and cystocele.
G.
Neurologic examination:
1.
Assess for tone, strength, and reexes to search for
focal decits and the delayed relaxation phase of the ankle
jerks, suggestive of hypo thyroidism.
H.
Pelvic examination:
1.
Evaluate for prolapse or rectocele. Evaluate when the
client is at rest and with straining.
I.
Psychiatric examination:
1.
Assess mental status for signs of depression and
somatization.
DIAGNOSTIC
A.
No tests are required for common constipation.
B.
Tests to rule out differential diagnoses:
1.
2.
3.
TESTS
Complete blood count with differential.
Thyroid studies.
Potassium and calcium: Clients taking diuretics should
have serum potassium checked. Hypokalemia may reduce
bowel contractility and produce an ileus.
4.
Urinalysis.
5.
Serum glucose to rule out diabetes.
6.
Barium enema (BE) to evaluate for megacolon and
redundant sigmoid colon.
7.
Flexible sigmoid or colonoscopy is recommended if the
client meets the guidelines for general screening or weight
loss greater than 10 lbs, anemia, or blood in the stool, or
clients with family history of CRC or inammatory bowel
disease.
8.
Stool for occult blood.
9.
Anorectal function tests:
a.
Manometry.
b.
Electromyography.
DIFFERENTIAL
A.
Constipation.
B.
Intestinal obstruction: Acute onset of constipation requires
DIAGNOSES
ruling out an ileus, especially when accompanied by abdominal discomfort.
C.
Hypothyroidism.
D.
Psychosocial dysfunction.
E.
Fecal impaction.
F.
Neurologic disorders.
G.
Multiple sclerosis.
H.
Spinal cord injury.
I.
CRC.
J.
Drug use.
K.
Crohn’s disease: Constipation is often the presenting
complaint.
L.
Diabetes (chronic dysmotility).
M.
HD.
PLAN
A.
General interventions:
1.
Reassure the client that recommended dietary changes
and exercise can help with constipation.
2.
Ask the client to keep a stool diary and bring the diary
to the next appointment.
B.
Client teaching: See Client Teaching Guide for this chapter,
“Constipation Relief.”
1.
Encourage the client to exercise. Both exercise and
dietary ber stimulate the natural wavelike contraction of
the colon that triggers the urge to defecate.
2.
Warn chronic laxative users that it may take 4 to 6
weeks before spontaneous BMs return.
3.
Teach the client about potential complications of
long-term constipation.
C.
Pharmaceutical therapy:
1.
Fiber supplementation.
2.
Bulk-forming agents decrease abdominal pain and
improve stool consistency. They should be used if an
increase in dietary ber does not work. They act by causing retention of uid and increasing fecal mass. They must
be taken with plenty of uids to prevent formation of an
obstructing bolus. Flatulence and abdominal distention
may occur, but long-term use is safe.
3.
Stimulant laxatives act by directly stimulating the
colonic nerves. Suppositories are faster (20–60 minutes)
versus oral laxatives (8–12 hours).
4.
Osmotic laxatives act by retaining uid in the bowel
by osmosis, changing the water distribution in the feces.
Good hydration is important (Table 11.5).
5.
Lubiprostone (Amitiza) 24 mcg orally BID is approved
for treatment of chronic idiopathic constipation (CIC) in
TABLE
11.5 LAXATIVES
Bulk laxatives Psyllium (Konsyl, Metamucil)
Lubricating agents Mineral oil
Stimulant laxatives Docusate
Osmotic agents Magnesium and phosphate salts
Selective 5-HT4
receptor agonists
Type 2 chloride
channel
Activator Lubiprostone (Amitiza)
Guanylate cyclase C
agonist
a
Considered
b
After
is hard to manage.
c
Tegaserod
d
The
younger than 18 years. Contraindicated in pediatric clients up to 6 years of age.
safe and effective in children.
a thorough evaluation, use in low doses in selected children when constipation
is prescribed under limited restrictive authority.
safety and efficacy of Linzess have not been established in pediatric clients
Polycarbophil
Methylcellulose (Citrucel)
a
Bile acids
Bisacodyl
Castor oil
Senna
b
a
Cascara
Aloes
Rhubarb
Lactulose (Kristalose)
a
Sorbitol
Polyethylene glycol (Colyte, Glycolax,
Miralax)
b
Glycerin suppositories
a
a
Prucalopride
Tegaserod (Zelnorm, HTF-919)
Linaclotide (Linzess)
d
c
CONSTIPATION
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347
adults, opioid-induced constipation in adults with chronic
noncancer pain, and IBS–constipation predominant in
females aged 18 years or older.
6.
Linaclotide (Linzess) has been approved by the Food
and Drug Administration (FDA) for treatment of CIC at a
dose of 145 mcg orally daily.
7.
Methylnaltrexone bromide (Relistor) 450 mg tablet
once per day is currently approved by the FDA for treatment of opioid-induced constipation in adult clients with
chronic noncancer pain.
8.
When severe depression requires the use of antidepres-
sants, the least constipating agent should be selected (i.e.,
one with minimal anticholinergic activity).
9.
Treat other identied causes, such as hypothyroidism.
D.
Dietary management:
1.
See Appendix B, “Diet Recommendations.”
E.
Medical management:
1.
Treatment of constipation is symptomatic and should
begin with lifestyle and dietary changes.
2.
Evaluate and stop medications, if possible, that cause
constipation.
3.
Glycerin suppositories may be needed for rectal disim-
paction in infants. Enemas are to be avoided.
4.
Fecal impaction may require enemas or manual
removal to relieve the situation. Enemas should not be
given routinely to treat constipation because they disrupt
normal defecation reexes and the client becomes dependent. Disimpaction by enema treatments includes three
enemas per day.
a.
The rst enema of the day includes the use of a
phosphate-based enema:
i.
Clients older than 12 years: one adult
phosphate-based enema, plus 1 L of saline solution.
ii.
Clients aged 4 to 12 years: one pediatric
phosphate-based enema, plus 1 L of saline solution.
iii.
Clients younger than 4 years: one half of a pedi-
atric phosphate-based enema, plus 500mL of saline
solution.
b.
The second and third enemas of the day include only
the saline solution and no phosphate-based enema.
c.
Clients should never receive more than one
phosphate enema per day due to the risk of phosphate intoxication, hypoglycemia, and hyponatremia.
d.
Soap suds, tap water, and magnesium enemas
in children are not recommended due to potential
toxicity.
5.
Pelvic oor physiotherapy may be offered.
6.
Biofeedback has been effective for short-term treat-
ment of intractable constipation.
7.
Manual removal of fecal impaction can stimulate the
vagus nerve and cause syncope and tachycardia. It is contraindicated in the following conditions:
a.
Pregnancy.
b.
After genitourinary, rectal, perineal, abdominal, or
gynecologic surgery.
c.
Myocardial infarction, coronary insufciency, pul-
monary embolus, congestive heart failure, or heart
block.
d.
GI or vaginal bleeding.
e.
Blood dyscrasias or bleeding disorders..
f.
Hemorrhoids, ssures, and rectal polyps
F.
Surgical management:
1.
In carefully selected clients with incapacitation chronic
constipation, subtotal colectomy with ileocecal anastomosis may be considered.
FOLLOW-UP
A.
Repeat assessment in 4 to 6 weeks. Ask the client to keep a
stool diary and bring it for subsequent appointments.
B.
If there is no evidence of obstruction, anemia, or occult
blood loss, follow the client expectantly for a few weeks on
a conservative program that includes increased dietary ber
and increased exercise, and follow stool guaiac.
C.
Failure to improve may indicate a serious underlying
cause and need for referral.
CONSULTATION/REFERRAL
A.
Consider consultations with a gastroenterologist (adult or
pediatric), pediatrician, gynecologist, surgeon, or psychologist/psychiatrist as indicated.
INDIVIDUAL
A.
Pregnancy:
1.
CONSIDERATIONS
Constipation is very common in pregnancy second-
ary to progesterone and the enlarging uterus (see the
“Pathogenesis” section).
2.
Constipation that results from iron supplementa-
tion can be avoided by increasing the intake of uid and
high-ber foods, and increasing physical activity such as
walking.
3.
Bulking agents and lactulose will not enter breast milk.
Senna, in large doses, will enter breast milk and may cause
diarrhea and colic in infants.
B.
Pediatrics:
1.
In infancy and childhood, most constipation is func-
tional. Constipation can be associated with coercive toilet
training, sexual abuse, excessive parental interventions,
and toilet phobia.
2.
An empty contracted anal canal in a constipated child
may suggest HD.
a.
Bloody mucoid diarrhea in an infant with a history
of constipation could be an indication of enterocolitis
complicating HD.
b.
If HD is suspected, the client should be evaluated by
a pediatric gastroenterologist and a pediatric surgeon.
3.
Reinforce the idea that each infant has individual stool
patterns. Formula-fed infants generally pass at least one
stool each day, whereas breastfed infants may pass a stool
after every feeding or, occasionally, only one every 2 to 3
days.
4.
Teach parent(s) and caregivers that regular BMs are
different for each child (once or twice a day or every other
day). Explain the stool consistency and appearance (dry,
hard, and marblelike stools) that could suggest the child is
constipated.
5.
Infants may get red in the face and appear to be strain-
ing when having a BM, but it is normal behavior and does
not indicate constipation.
6.
Rectal prolapse in children has been associated with
cystic brosis.
7.
Use a high-ber diet and uids rst before other
therapies. Prune, pear, and apple juices may decrease
constipation.
8.
Common times when constipation is likely to occur in
the pediatric population:
a.
Upon introduction of solid foods or cow’s milk:
i.
Recommended ber intake is 20 g/d.
ii.
Minimum uid intake depends on the child’s
age.
iii.
Consumption of cow’s whole milk should be
limited to 24 oz/d.
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