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• Trauma
• Endoscopic retrograde cholangiography (see Table 8-8)
• Metabolic disorders
• Vasculitis
• Pancreatic obstruction
• Penetrating peptic ulcer
• Genetic predisposition
• Renal failure
• Hepatitis
• Medications
• Postoperative sequelae from abdominal or cardiothoracic surgery
Signs and symptoms of acute pancreatitis include the following· ..... s:
• Steady, dull abdominal pain in the epigastrium, left upper quadrant or periumbilical area often radiating to back, chest, and lower abdomen. rain can be exacerbated by food, alcohol, vomiting, and
resting in the supine position.
• Nausea, vomiting, and abdominal distention
• Fever, tachycardia, and hypotension (in acure cases)
• Jaundice
• Abdominal tenderness or rigidity
• Diminished or absent bowel sounds
• Associated pulmonary manifestations, such as pleural effusions
and pneumonitis
• Decreased urine output
• Weight loss
GASTROINTfSTJNAL SYSTEM
547
Management of acute pancreatitis includes any of the followint�5:
• Pain management, generally with narcotics, possibly through
patient-controlled analgesia (See Appendix VI.)
• i.v. Auid and electrolyte replacement
• Elimination of oral food intake and providing alternative nutritional support, such as rotal parenteral nutrition
• Surgical correction or resection of obstructions
• Antacids
• Nasogastric slIctioning
• Supplemental oxygen and mechanical ventilation (as indicated)
• Invasive monitoring (in more severe cases)
Management
General management of GI disorders may consist of any of the following: pharmacologic therapy, nutritional support, dietary modifications, and surgical procedures. Nutritional suppOrt and dietary modifications are beyond the scope of this book. This section focuses
on pharmacologic therapy and surgical procedures. A discussion of
physical therapy intervention is also included.
piJamracologic Therapy
Medications used to treat GI disorders can be broadly categorized as
(I) those that control gastric acid secretion and (2) those that normalize gastric motility. Refer to Appendix IV (Tables 1Y.19 A-B and IV.20
A-B) for an overview of these medications. Other medications that do
not fall into these categories are mentioned in specific sections under
Parhophysiology, earlier in the chapter.
Surgical Procedures
Surgical intervention is indicated in GI disorders when medical intervention is insufficient. The location and extent of incisions depend on
548
AClITE CARE HANDBOOK FOR PHYSICAl THERAI'ISTS
the exact procedure. The decision to perform either an open laparotomy or a laparoscopic repair will be dependent on physician preference based on surgical difficulty. However, with the progress of laparoscopic technology, many open laparotomy procedures requiring large abdominal incisions are being replaced with laparoscopic procedures. Laparoscopic procedures have been shown to reduce hospital length of stay, many postoperative complications, or both·2•
62.66.67 Postoperative complications may include pulmonary infection,
wound infection, and bed rest deconditioning. Please refer to Appendix V for further descriptions of the effects of anesthesia.
The following is a description of the more common GI surgical
proced u resJ9,42,62,66-70;
Appendectomy
Removal of the appendix. Performed either
through open laparotomy or laparoscopically.
Cholecystectomy
Removal of the gallbladder. Generally performed laparoscopically.
Colectomy
Resection of a portion of the colon. The name
of the surgical procedure generally includes the
section removed (e.g., transverse colectomy is
resection of the transverse colon). A colectomy
may also have an associated colostomy or ileostomy. Performed either through open laparotomy or laparoscopically.
Colostomy
A procedure used to divert stool from a portion of the diseased colon. There are three general types of colostomies: end, double-barrel, and loop colostomy.
End colostomy
Involves bringing the functioning end of the
intestine (the section of bowel that remains
connected to the upper GI tract) out OntO the
surface of the abdomen and forming the stoma
by cuffing the intestine back on itself and
suturing the end to the skin.
Double·barrel
Two separate stomas are formed on the
colostomy
abdominal wall. The proximal stoma is the
functional end that is connected to the upper
GI tract and will drain stool. The distal stoma,
also called a mucous fistula, is connected to the
rectum to drain small amounts of mucus material. This is most often a temporary colostomy.
GASTRQINfESTINAL SYSTEM
549
Loop colostomy
Created by bringing a loop of bowel through
an incision in the abdominal wall. An incision
is made in the bowel to allow the passage of
stool through the loop colostomy. Also used as
a temporary colostomy.
Gastrectomy
Removal of a portion (partial) or all (total) of
the stomach. Partial gastrectomy may either be
a Billroth I or Billroth II procedure.
Billroth I
Resection of the pyloric portion of the stomach.7°
Billroth /I
Resection of the distal portion of the stomach
and the duodenum.7o
Ileostomy
A procedure similar to a colostomy and is performed in areas of the ileum (distal portion of
the small intestine). A cOlltinent ileostomy is
another method of diverting stool that, instead
of draining into an external pouch, drains
either inro morc distal and functioning portions
of the intestine or into an internal pouch that is
surgically created from the small intestines.
Resection and
The removal (resection) of a non functioning
reanastomosis
portion of the GI tract and the reconnecrion
(reanastomosis) of proximal and distal GI portions that are functional. The name of the procedure will then include the sections that are resected or reanasromosed-for example, a
pallcreaticojejullostomy is the joining of the
pancreatic duct to the jejunum after a dysfunctional portion of the pancreas is resecred.64.6S
Whipple procedllre
Con ists of ell bloc removal of the duodenum,
(pallcrea ticoduoa variable portion of the distal stomach and
denectomy)
the jejunum, gallbladder, common bile duct,
and regional lymph nodes. This removal is followed by pancreaticojejunostomy and gastrojejunostomy. This procedure is reserved for the patient with severe or unremitting chronic
pancreatitis or pancreatic cancer.64,6S,71
New GI slIrgical Transplantation of various parts of the GI sysprocedures
tem, including the stomach and intestines, is
being investigated as a possible mechanism to
alleviate GI dysfunction in various patient populations.