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11: GASTROINTESTINAL GUIDELINES
TABLE
11.21 DEFINITION OF SEVERITY OF
ULCERATIVE COLITIS
Mild UC ≤4 bloody stools per day with or without blood
No systemic toxicity
Normal ESR
Mild abdominal pain or cramping
Moderate UC >4 bloody stools per day
No signs of systemic toxicity
Pulse <90 beats per minute
Temperature <37.5°C (99.5°F)
Hgb >10.5 g/dL
ESR <30mm/hr
Moderate abdominal pain
Acute severe UC
a
36 bloody stools per day or observable
massive and significant blood BM and
One or more symptoms of systemic toxicity
Tachycardia >90 beats per minute
be considered a desirable nal outcome but is useful to
assess early response to treatment.
INCIDENCE
A.
The annual incidence of UC is 10.4 to 12 per 100,000,
depending on the country.
B.
UC is three times more common than CD.
C.
The most common cause of death in clients with UC is
toxic megacolon.
D.
Adenocarcinoma of the colon develops in 3% to 5% of
clients with UC; the risk increases with the duration of the
disease.
E.
Approximately 6.2% of clients with IBD have a major
extraintestinal manifestation:
1.
Uveitis is the most common: 3.8%.
2.
Primary sclerosing cholangitis (PSC): 3%.
3.
Ankylosing spondylitis: 2.7%.
4.
Erythema nodosum: 1.9%.
5.
Pyoderma gangrenosum: 1.2%.
PATHOGENESIS
A.
The exact etiology is unknown but may include a mix of
immune response, genetics, and environmental factors.
B.
UC may be considered an autoimmune disease. Persons
with UC often have p-antineutrophil cytoplasmic antibodies (p-ANCAs). Abnormalities of humoral and cell-mediated
immunity and/or generalized enhanced reactivity against
intestinal bacterial antigen may also be causes of UC.
Temperature >37.8°C (100.4°F)
Hgb >10.5 g/dL
Increased ESR (>30mm/hr)
Fulminant UC >10 stools per day
Continuous rectal bleeding
Systemic toxicity
Tachycardia >90 beats per minute
Fever >37.8°C (100.4°F)
Anemia requiring blood transfusions
Abdominal tenderness and distention
Colonic dilation on radiography
May lead to toxic megacolon or colonic
perforation
a
severe colitis is defined by Truelove and Witt’s Criteria (1955).
Acute
BM,
bowel movement; ESR, erythrocyte sedimentation rate; Hgb, hemoglobin; UC,
ulcerative colitis.
1.
Complete remission: both symptomatic remission and
endoscopic healing dened as follows:
a.
Endoscopic healing: normal mucosa, vascular blur-
ring, or chronic changes (e.g., inammatory polyps,
scarring) without friability.
b.
Symptomatic remission: normal stool frequency
(less than or equal to 3/d) and no blood in the stool.
2.
Symptomatic response: meaningful improvement in
symptoms as judged by both the client and the physician in the absence of remission; response should not
PREDISPOSING
A.
Caucasian.
B.
Jewish descent.
C.
Affects 30% more females than males.
D.
Genetic susceptibility: Family history is associated with a
FACTORS
higher risk of developing the disease.
COMMON
A.
B.
C.
D.
E.
F.
G.
H.
OTHER
A.
COMPLAINTS
Frequent small-volume diarrhea.
Bloody diarrhea with or without mucus.
Severe bowel urgency.
Abdominal cramps and pain with bowel movement (BM).
Constipation in clients with distal disease.
Anorexia.
Anemia.
Nocturnal BMs.
SIGNS AND SYMPTOMS
Tenesmus (rectal urgency/constant feeling of need to pass
stool).
B.
Abdominal tenderness.
C.
Arthralgias.
D.
Fatigue secondary to anemia.
E.
Failure to thrive in children.
F.
Severe UC:
1.
Fever.
2.
Tachycardia.
3.
Signicant abdominal tenderness.
4.
Signs of volume depletion.
SUBJECTIVE
A.
Review the onset, duration, signs, and symptoms (number
DATA
of stools, presence/absence of blood in the stool, fever, and
abdominal pain).
B.
Review the client’s recent history of travel or camping
trips for the presence of intestinal infection.
C.
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Review the client’s medication history including antibi-
otics and nonsteroidal anti-inammatory drugs (NSAIDs):
One-third of clients with exacerbation of UC report recent
NSAID use.
D.
Review family history for IBD, celiac disease, and colorec-
tal cancer (CRC).
E.
Review the client’s smoking status.
F.
Review the client’s history or contact related to tuberculo-
sis (TB) (testing required before biological therapy).
G.
Evaluate if the client has symptoms of uveitis, including
light sensitivity, oaters, blurry vision, or pain/tenderness to
touch.
PHYSICAL
A.
Check temperature, pulse, blood pressure, and weight.
EXAMINATION
Follow serial weights.
B.
Inspect:
1.
Observe the client’s general overall appearance for
nutritional status, cachexia, and pallor.
2.
Observe the perianal region for presence of tags, s-
sures, stulas, and abscess.
3.
Observe the abdomen for distention and presence of
surgical scars.
4.
Examine the eyes for redness, irritation, and ocular
complications (episcleritis, scleritis, and uveitis).
5.
Evaluate for presence of dermatologic ndings, includ-
ing erythema nodosum and pyoderma gangrenosum.
C.
Auscultate:
1.
Heart.
2.
Lungs.
3.
Abdomen: all four quadrants.
D.
Percuss:
1.
Abdomen for organomegaly, masses, ascites, and
hepatic tenderness. Look for tympany on percussion as a
potential sign of colonic dilation.
E.
Palpate:
1.
Palpate all four quadrants of the abdomen, observing
for tenderness, rebound, and guarding.
2.
Evaluate for presence of hepatomegaly.
3.
Perform a digital rectal examination to assess for anal
strictures and rectal masses.
4.
Palpate the joints for warmth, tenderness, and range of
motion.
DIAGNOSTIC
A.
Diagnosis is best made with endoscopy and biopsy.
B.
Laboratory tests:
1.
2.
3.
4.
5.
6.
C.
Stool testing:
1.
2.
3.
D.
Plain abdominal radiograph.
E.
CT scan.
F.
MRI.
G.
Ultrasound.
H.
Double-contrast barium enema.
I.
Celiac antibody testing should be considered.
J.
Intestinal TB testing should be considered.
TESTS
Complete blood count (CBC) with electrolytes.
Platelet count.
Sedimentation rate.
C-reactive protein.
Cytomegalovirus (chronic immunosuppressive steroids).
HIV.
Evaluate bacterial, viral, or parasitic causes of diarrhea.
Occult blood.
Fecal leukocytes.
ULCERATIVE COLITIS
DIFFERENTIAL
A.
UC.
B.
Ischemic colitis (especially in the elderly).
C.
Toxic megacolon.
D.
Colon cancer.
E.
Adenocarcinoma.
F.
Rectal cancer.
G.
Radiation colitis.
H.
Intestinal infections.
I.
Intestinal lymphoma.
J.
Chronic diverticulitis.
K.
Amebiasis.
L.
CD.
DIAGNOSES
PLAN
A.
General interventions:
1.
See Table 11.21 for the denition of severity of UC.
2.
Severe UC should be managed jointly by a gastroen-
terologist in conjunction with a colorectal surgeon (Table
11.22).
3.
Stress reduction and stress management may improve
symptoms.
4.
Pretreatment screening for TB, using Mantoux (a puri-
ed protein derivative) skin testing, is needed before initiation of immunomodulators and thiopurines.
5.
Immunization status:
a.
Immunizations with inactivated vaccine should be
brought up to date and rigorously maintained during
treatment, including inuenza, meningococcal, and
pneumococcal immunizations.
b.
Check varicella titers prior to treatment with immu-
nomodulators and reimmunize if titers are low.
c.
The risk of administering live vaccines (polio,
rubella, and yellow fever) to clients on immunomodulators has not been established; however, most experts
avoid live vaccines during treatment.
B.
Client teaching: See Client Teaching Guide for this chapter,
“Crohn’s Disease.”
C.
Pharmaceutical therapy:
1.
Refer to the American College of Gastroenterology
(ACG) Practice Guidelines for full treatment algorithms
at s3.gi.org/physicians/guidelines/UlcerativeColitis.pdf,
or the 2015 Toronto Consensus Guidelines for the
Management of UC algorithms at www.cag-acg.org/
images/publications/cpg_toronto_consensus_on_uc_
may2015.pdf.
2.
The choice of topical agents is guided by the proximal
distribution of UC into the bowel, as well as client preference (see Table 11.22).
TABLE
11.22 MANAGEMENT OF MILD-TOMODERATE DISTAL ULCERATIVE COLITIS WITH
TOPICAL AGENTS
Topical Agent
Suppository 10cm
Hydrocortisone foam 15–20cm
Enema As far as the splenic flexure
Proximal Extent/Distribution of
Agent
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3.
11: GASTROINTESTINAL GUIDELINES
Stepwise medication approach (see Table 11.6): The
5-ASA class of anti-inammatory drugs is the most common treatment for clients with mild (less than four bloody
stools per day) or moderate active disease (more than four
bloody stools a day without systemic toxicity):
a.
Sulfasalazine (Azuldine) for mild-to-moderate UC
and remission maintenance:
i.
Pediatrics: 50 to 75 mg/kg each 24 hours,
divided into three to four doses.
ii.
Reduced absorption of folic acid and digoxin
has been reported when they are administered
with sulfasalazine.
b.
Balsalazide (Colazal) for mild-to-moderate UC and
remission maintenance:
i.
Induction: 6.75 g/d, TID dosing.
ii.
Maintenance: 2 to 6.75 g/d, BID dosing.
iii.
Pediatric dose: 5 years or older: 750 mg, TID
dosing for up to 8 weeks.
4.
Mesalamine for mild-to-moderate UC and remission
maintenance:
a.
Asacol:
i.
Pediatrics: For clients 5 years or older, dosage is
weight-based (up to a maximum of 2.4 g/d), divided
into two daily doses for a duration of 6 weeks.
ii.
Two Asacol 400 mg tablets are not inter-
changeable or substitutable with one mesalamine
delayed-release 800mg tablet.
b.
Apriso: 1.5 mg/d orally in the morning.
c.
Salofalk: 1 to 4 g/d in one or two divided doses:
i.
Also available as a suppository, rectal suspen-
sion, and enema.
d.
Pentasa: 1 g/d orally, QID dosing for up to 8 weeks:
i.
Also available as a suppository.
e.
Multi-Matrix System (MMX) marketed as Lialda:
active to moderate UC:
i.
Induction: 2.4 to 4.8 g/d for up to 8 weeks.
ii.
Maintenance: 2.4 g/d.
iii.
Lialda is not recommended for children younger than
18 years.
f.
Rowasa enema: 4 g/60mL rectally at bedtime; retain
for approximately 8 hours.
g.
Mesalamine (Canasa) suppository 1 g/d at bedtime;
retain in the rectum for at least 1 to 3 hours. Treat active
proctitis for 3 to 6 weeks.
5.
Corticosteroids suppress the immune system and are
used for moderate-to-severe UC.
a.
Prednisone (Deltasone, Orasone):
i.
Induction: 40 to 60 mg/d PO for 7 to 14 days,
followed by gradual taper by 5 mg/wk.
ii.
Maintenance: 2.5 to 5 mg/wk.
b.
Budesonide (Entocort EC):
i.
Pediatric: For clients 8 to 17 years old who weigh
more than 25kg: 9 mg orally for up to 8 weeks, followed by 6 mg once a day for 2 weeks.
6.
Immune modiers are used to reduce corticosteroid
dosage.
a.
Azathioprine (AZA; Imuran) 2 to 3 mg/kg/d orally:
i.
Monitoring includes CBC, including plate-
let counts weekly during the rst month, twice
monthly for the second and third months of therapy, then monthly or more frequently if dosage
alteration is necessary.
ii.
Thiopurine methyltransferase (TPMT) testing:
Testing is recommended for either genotype- or
phenotype-identied clients for TPMT.
b.
6-Mercaptopurine (Purinethol) 1 to 1.5 mg/kg/d
orally:
i.
Clients with little or no inherited TPMT activity
are at increased risk for severe purinethol toxicity
and generally require substantial dose reduction.
ii.
Pediatrics: 1.0 to 2.0 mg/kg/d orally (maxi-
mum 150mg/d).
c.
Cyclosporine (Neoral, Sandimmune):
i.
Intravenous (IV) infusion: 2 to 4 mg/kg/d.
ii.
Can be switched to a doubled oral dose for out-
patient therapy; used only short term.
7.
Antibiotics:
a.
Ciprooxacin (Cipro) 500mg orally BID.
b.
Metronidazole (Flagyl).
8.
Biological therapy (anti-TNF agents) for moderate-to-
severe UC. A tuberculin skin test is recommended before
therapy. Clients started on iniximab should also be
screened for hepatitis B before initiating therapy.
Iniximab (Remicade) infusion therapy has a
a.
half-life of approximately 10 days.
b.
Adalimumab (Humira) for treatment of moderate-to-
severe UC:
i.
Pediatrics: not recommended for those younger than
18 years.
c.
Golimumab (Simponi):
i.
Initial dosage: 200mg subcutaneously at week 0.
ii.
Second dose (week 2): 100mg.
iii.
Maintenance dose: 100mg every 4 weeks.
d.
Vedolizumab (Entyvio):
i.
Initial dose: 300mg IV at weeks 0, 2, and 6.
ii.
Maintenance dose: 300mg IV every 8 weeks of
therapy.
iii.
Discontinue if no evidence of therapeutic ben-
et by week 14.
D.
Dietary management:
1.
Adequate nutrition is critical to promotion of heal-
ing. Sufcient protein and calories limits the stress on an
inamed bowel.
2.
Many clients with UC have concurrent lactose intol-
erance. (See Appendix B “Diet Recommendations,” for
lactose-intolerance dietary recommendations.)
3.
Decrease dietary ber during increased disease activity.
4.
A low-residue diet may decrease the frequency of BMs.
5.
A high-residue diet may be helpful in ulcerative proc-
titis when constipation is the dominant symptom (see
Appendix B, Table B.6).
E.
Surgical management:
1.
Indications for considering a total colectomy:
a.
Failed medical therapy: refractory UC.
b.
Severe hemorrhage.
c.
Fulminate colitis not responsive to treatment.
d.
Toxic megacolon.
e.
Obstruction or stricture.
f.
FTT in children.
2.
Indications for considering elective surgery:
a.
Long-term steroid dependence.
b.
Dysplasia or adenocarcinoma found on screening
biopsy.
c.
Disease present 7 to 10 years.
ULCERATIVE COLITIS
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FOLLOW-UP
A.
Screening colonoscopy is recommended for all clients with
UC for 8 years after the onset of symptoms due to the increase
in colonic neoplasia; it should be repeated every 5 years if they
do not have any intermediate or high risk factors.
B.
Clients with extensive UC or left-sided colitis with nega-
tive ndings on the screening colonoscopy should begin surveillance colonoscopy in 1 to 2 years.
C.
Clients with mild-to-moderate inammation and a
rst-degree relative with CRC are considered intermediate
risk; screening colonoscopy is recommended every 3 years.
D.
Annual screening colonoscopy is recommended for clients
with high risk factors, including presence of PSC, moderate-tosevere active inammation sustained over time, rst-degree
relative with CRC at an age younger than 50 years, or stenosis
or dysplasia detected during the previous 5 years.
E.
Steroids should not be used as maintenance therapy.
Clients who require long-term steroids are at increased risk of
osteoporosis.
F.
Subsequent laboratory monitoring tests depend on the
prescribed therapy.
G.
Rates of anxiety and depression are higher in clients with
IBD. Screen for depression at each visit.
CONSULTATION/REFERRAL
A.
Gastroenterologist for conrmatory diagnosis with a
colonoscopy.
B.
Surgeon for severe or fulminant colitis. Toxic megacolon
is a life-threatening complication and requires urgent surgical
intervention.
C.
Clients with ocular complications require an urgent
consultation.
D.
Clients who have had UC for 8 to 10 years are at risk
of colon cancer; therefore, colonoscopy for surveillance is
recommended.
3.
Children may present with systemic complaints,
including fatigue, arthritis, failure to gain weight, and
delayed puberty.
B.
Adults:
1.
Live vaccinations should not be administered to immu-
nocompromised clients. If required, vaccines should be
administered at the time of UC diagnosis.
a.
The u and pneumonia vaccines should be rou-
tinely administered.
b.
Consider administering the human papillomavirus
vaccine.
2.
Females with IBD have reported to have a high inci-
dence of abnormal Pap smears. Adherence to Pap smear
guidelines is recommended by the ACG.
3.
Abnormal sperm counts, motility, and morphology are
seen with sulfasalazine.
RESOURCES
American
Crohn’s
College of Gastroenterology: gi.org
and Colitis Foundation of America: www.ccfa.org
BIBLIOGRAPHY
Bressler, B., Marshall, J. K., Berstein, C. N., Bitton, A., Jones, J., Leontiadis, G.
I., & Fegan, B. (2015). Clinical practice guidelines for the medical management of nonhospitalized ulcerative colitis: The Toronto consensus.
Gastroenterology, 148, 1035–1058. https://doi.org/10.1053/j.gastro.2015.
03.001
Crohn’s and Colitis Foundation of America. (n.d). Types of ulcerative
colitis. http://www.ccfa.org/what-are-crohns-and-colitis/what-is-
ulcerative-colitis/types-of-ulcerative-colitis.html
Ko, C., Singh, S., Feuerstein, J., Falck-Yttr, C., Falck-Yttr, Y., & Cross, R.
(2019). AGA clinical practice guidelines of management of mild-tomoderate ulcerative colitis. American Gastroenterological Association
Institute Clinical Guidelines Committee. Journal of Gastroenterology,
156(3), 748–764. https://doi.org/10.1053/j.gastro.2o18.12.009
INDIVIDUAL
A.
Pediatrics:
1.
2.
CONSIDERATIONS
UC is uncommon in persons younger than 10 years.
Fulminant disease occurs more in children than in
adults.
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CLIENT
TEACHING GUIDE
ABDOMINAL PAIN: ADULTS
PROBLEM
recently; recurrent pain is present on three or more separate occasions over at least a 3-month period.
It
is important that you call the healthcare provider if you have pain that lasts 3 hours or longer, have fever, vomiting, or pain that
is unusually sharp or intense.
CAUSE
is the most common cause of acute pain, and chronic stool retention (constipation) is the most common cause of chronic pain.
Urinary tract infections (UTIs) can also cause abdominal pain.
A.
Males: Torsion of the testicles or a strangulated inguinal hernia may cause abdominal pain.
B.
Females: If you have missed a period or suspect you are pregnant, tell your healthcare provider; ectopic pregnancies are a
medical emergency.
PREVENTION/CARE
A.
Go to the bathroom as soon as you have the urge to have a bowel movement (BM).
B.
Establish a regular toilet time such as after breakfast; 15 to 20 minutes after breakfast provides a good time because sponta-
neous colonic motility is greatest during this period.
TREATMENT
for suspected abdominal pain and the following:
A.
Increased or odd-looking vomit or stools.
B.
Hard, swollen abdomen.
C.
Lump in scrotum, groin, or lower abdomen.
D.
Missed period or suspected pregnancy.
Problems
Pain
may result from inammation, ischemia (poor blood supply), distention, constipation, or obstruction. Gastroenteritis
PLAN Do
relating to abdominal organs may range from simple gas to appendicitis. Acute pain is pain that has started
The
following suggestions can prevent abdominal pain from constipation:
not take laxatives, enemas, drugs, food, or liquids (including water) until consulting your healthcare provider
Activity:
Engage in activity as tolerated. Abdominal pain with nausea and vomiting, with fever, or pain that lasts more than 3 hours
and makes you stop doing daily activities should be reported.
Diet:
Eat regular foods as tolerated. Do not eat food or drink liquids until you see a healthcare provider if you have pain with nau-
sea and vomiting, with fever, or pain that lasts longer than 3 hours.
Medications:
You
Have Been Prescribed:
You
Need to Take:
You
Need to Notify the Office If You Have:
A.
Any change in the rst symptoms that brought you to the ofce.
B.
Fever higher than
C.
Other:
Phone:
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CLIENT
TEACHING GUIDE
ABDOMINAL PAIN: CHILDREN
PROBLEM
if your child has abdominal pain that lasts 3 hours or longer, has a fever, vomiting, or pain that is unusually sharp or intense. Signs
that your child has abdominal pain include lying down and drawing their knees into the stomach; crying when you try to touch their
stomach; or pointing to an area, such as the navel, when crying.
CAUSE
enteritis) is the most common cause of acute pain. Chronic pain happens if your child holds in bowel movements (BMs), which
causes constipation. Urinary tract infections can cause abdominal pain, and often the child with a bladder infection does complain
of burning on urination and having to go to the bathroom more often.
PREVENTION/CARE
A.
Tell your child to go to the bathroom as soon as they feel the urge to go.
B.
If possible, set up a regular toilet time, such as 15 to 20 minutes after breakfast or after school.
TREATMENT
healthcare provider for suspected abdominal pain and the following:
A.
Unusual cry, especially loud crying.
B.
Increased or odd-looking BMs or vomiting.
C.
Hard, swollen abdomen.
D.
Lump in scrotum, groin, or lower abdomen (tummy).
E.
If you notice pain symptoms, especially if when the child bends their legs, draws the knees to their chest, and/or points to their
navel.
Pain
in your child’s “tummy” may range from simple gas to appendicitis. It is important to call the healthcare provider
Pain
may result from inammation, distention, constipation, or obstruction. A gastrointestinal (GI) stomach bug (gastro-
There
is no way to prevent stomach pain, but the following can prevent abdominal pain from constipation:
PLAN Do
not give laxatives, enemas, drugs, herbal products, food, or liquids (including water) until consulting your
Activity:
Allow activity as tolerated. Children may not be able to tell you in words what is wrong with them. Children tell you they
are in pain with a change in the pitch of their crying and by making faces (grimacing). For example:
A.
Refusing to eat or breastfeed.
B.
Drawing knees to tummy when you touch the stomach.
Diet:
Do not give baby food or liquids until you see a healthcare provider if you notice a change in the pitch of your baby’s crying,
facial grimacing, refusal to suck, or your child draws the knees up to their stomach, especially after being touched.
Medications:
You
Have Been Prescribed:
You
Need to Take:
You
Need to Notify the Office If You Notice That Your Child Has:
A.
Any change in the rst symptoms that brought you to the ofce.
B.
Fever higher than
C.
Other:
Phone:
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CLIENT
TEACHING GUIDE
CELIAC DISEASE
PROBLEM
wheat, rye, or barley. People with celiac disease can experience diarrhea, abdominal discomfort, bloating, weight loss, and nutri-
tional deciencies.
CAUSE
intestine is responsible for absorbing nutrients. When there is a damage to the small intestine, the absorption of the nutrients is
affected, which causes malabsorption.
PREVENTION/CARE
A.
Maintain a gluten-free diet. Avoid foods containing wheat, rye, or barley.
B.
Consult a dietitian regarding the foods to avoid and the foods to add for nutritional balance.
C.
Discuss the need for vitamin and nutritional supplementation with your healthcare provider.
D.
Keep all your follow-up appointments with your healthcare provider.
TREATMENT
A.
Eat a strict gluten-free diet.
B.
Take vitamin and nutritional supplements as directed by your provider.
C.
Untreated celiac disease can increase the risk of certain gastrointestinal cancer. Eating a gluten-free diet reduces this risk.
Medications:
as needed for any deciencies.
Celiac
disease is a condition where a protein called gluten can damage the lining of the small bowel. Gluten is found in
The
exact cause of celiac disease is not clear. Environmental and genetic factors contribute to this condition. The small
PLAN
There are no medications to treat celiac disease. Your physician may prescribe vitamin and nutritional supplements
You
Have Been Prescribed:
You
Need to Take:
You
Need to Notify the Office If You Have:
A.
Severe abdominal pain.
B.
Diarrhea causing dehydration.
C.
Other:
RESOURCE
Kelli,
C.P., & Dennis, M. (2018, Oct 8). Patient education: Celiac disease in adults (beyond the basics). UpToDate.
https://www.uptodate.com/contents/celiac-disease-in-adults-beyond-the-basics#H21
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CLIENT
TEACHING GUIDE
CHOLECYSTITIS
PROBLEM
men, beneath your liver. Clients with cholecystitis can experience pain in the right upper or middle of the abdomen, and the pain
might spread to your right shoulder or back. Other symptoms may be nausea, vomiting, and/or fever.
CAUSE
tions, decreased blood ow to gallbladder, bile duct problems, and tumors.
PREVENTION/CARE
A.
Maintain a healthy body weight. This decreases chance of formation of gallstones.
B.
Chose a healthy diet.
C.
Lose weight slowly. Rapid weight loss can increase the risk of gallstones.
D.
Exercise regularly, 30 minutes, 5 days per week.
TREATMENT
A.
You may need to get admitted to the hospital if your symptoms are severe.
B.
Surgery: Gallbladder may need to be removed depending on the severity of your symptoms.
C.
Procedure: Your doctor may perform a procedure to remove any stones that block the bile duct.
Medications:
A.
Pain medications to help control the pain.
B.
Antibiotics to ght infection.
C.
Bile acid pills can break down certain types of gallstones. However, it may take several years for these stones to disappear with
this treatment.
Cholecystitis
Most
commonly, gallstones that form inside the gallbladder are the cause of cholecystitis. Other causes include infec-
is the inammation of the gallbladder. Your gallbladder is situated in the right upper side of your abdo-
PLAN
You
Have Been Prescribed:
You
Need to Take:
You
Need to Notify the Office If You Have:
A.
Severe abdominal pain.
B.
Fever.
C.
Other:
RESOURCE
Zakko,
S.F. (2018, Feb 21). Patient education: Gallstones (beyond the basics). UpToDate. https://www.uptodate.com
/contents/gallstones-beyond-the-basics
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CLIENT
TEACHING GUIDE
COLIC: WAYS TO SOOTHE A FUSSY BABY
PROBLEM
that cannot be explained; crying may range from fussiness to screaming; and crying that follows a pattern:
A.
It occurs at the same time of the day, usually late afternoon or evening.
B.
The crying episodes last a total of more than 3 hours per day and infants are difcult to soothe.
C.
It usually begins at 3 weeks of age and lasts through 3 to 4 months of age.
D.
The baby’s stomach may rumble, and then the baby may draw up their legs as if in pain.
E.
No specic cause or disease can be found.
CAUSE
PREVENTION/CARE
TREATMENT
A.
Record the time when colic episodes occur. Soothe and comfort your baby before the “attack.”
B.
Do not feed your baby every time they cry. Look for a reason, such as a gas bubble, cramped position, too much heat or cold,
soiled diaper, or a desire to be cuddled.
C.
Make sure your baby is not overfed or underfed (see the “Diet” section that follows). During an attack of gas, hold your baby
securely and gently massage their lower abdomen. Rocking may be soothing.
D.
Feed your baby with the head up, such as sitting up, and use frequent burping.
E.
Using a collapsible bag/bottle may help reduce air-swallowing.
F.
Do not give your baby any herbal products without a healthcare provider’s approval.
Your
baby has been diagnosed with colic if the following symptoms are noticed: repeated episodes of excessive crying
The
cause of colic is unknown.
There
are no specic preventive measures. Remove any causes that can be identied.
PLAN
Activity:
A.
Overstimulation may cause infant upset. A quiet environment or being left alone in the crib to work off excess tension may be
necessary.
B.
Allow your baby to cry if you are certain that everything is all right. Colic is distressing, but not harmful.
C.
Take time away from your infant to rest and recoup.
D.
Try the following remedies:
1.
Rhythmic rocking; use swings.
2.
Car rides.
3.
Walking the baby in a stroller.
4.
Running vacuum or vaporizer for calming noise.
5.
Giving your baby a pacier for sucking.
6.
Swaddling and cuddling to soothe the baby.
7.
Playing music to quiet the baby.
E.
If you are breastfeeding, review all of your medications and any herbal products that you are taking with your healthcare
provider.
Diet:
A.
Your baby should be taking at least ___________________________________________________________ oz of ______________
_____________________________________________ formula at each feeding. Interrupt bottle feedings halfway through the feeding
and burp the baby. Burp your baby at the end of the feeding, too.
B.
If breastfeeding, do not switch to formula unless you have discussed it with a healthcare provider. Interrupt breastfeeding every
5 minutes to burp. If breastfeeding, you should avoid eating the following foods: chocolate, cabbage, beans, pizza, or spicy foods.
C.
Allow at least 20 minutes to feed your baby. Hold your baby while they are feeding; do not prop the baby with a bottle for
feeding.
D.
Do not try a home remedy, such as feeding homegrown mint teas, to your baby.
You
Need to Notify the Office If:
A.
The baby has a rectal temperature of 100.4°F or higher.
B.
You fear you are about to lose emotional control or afraid that someone has shaken the baby.
C.
Your baby is taking a prescription drug and new unexplained symptoms develop; the drug may produce side effects.
(continued)
From FAMILY PRACTICE GUIDELINES, Sixth Edition. Copyright Springer Publishing Company, LLC. All Rights Reserved.
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