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ACUTE CARE HANDBOOK FOR PHYSICAL THERAPISTS

Management of herniation includes any of the foliowingJ9,,,:

• Wearing a binder or corset

• Herniorrhaphy (surgical repair, typically with a laparoscope)

• Hernioplasty (surgical reinforcement of weakened area with

mesh, wire, or fascia)

• Temporary colostomy in cases of intestinal obstruction

Hiatal Hernia

A hiatal hernia is an abnormal protrusion of the stomach upward

through the esophageal hiatus of the diaphragm. Causative risk factors for a hiatal hernia are similar to those for abdominal hernia.

Clinical manifestations include heartburn-like epigastric pain that

usually occurs after eating and with recumbent positioning.

Management of hiatal hernia can include behavior modifications,

such as avoiding reclining after meals, eating spicy or acidic foods,

drinking alcohol, and smoking tobacco. Eating small, frequent, bland

meals containing high fiber content may also be beneficial. Pharmacologic intervention typically includes acid-reducing medications.45 In certain cases, when these measures have proven ineffective, surgical

management of the hiatal hernia can be performed laparoscopically.46

Clinical Tip

Positions associated with bronchopulmonary hygiene or

functional mobility may exacerbate pain in patients who

have a hernia, particularly a hiatal hernia. Therefore, careful modification of these interventions will be necessary for successful completion of these activities.

lntestinal Obstructions

Failure of intestinal contents to propel forward can occur by mechanical or functional obstructions. Blockage of the bowel by adhesion, herniation, volvulus (twisting of bowel on itself), tumor, inflammation, impacted feces, or invagination of an adjacent bowel segment constitutes mechanical obstructions. Loss of the propulsive activity of

the intestines leads to functional obstructions (paralytic ilells).

Obstructions may result from abdominal surgery, intestinal disten-

GASTROINTESTINAL SYSTEM

533

tion, hypokalemia, peritonitis, severe trauma, spinal fractures, ureteral distention, or use of narcotics.J9.40

Signs and symptoms of intestinal obstructions include the

following39 ••• :

• Sudden onset of crampy abdominal pain that may be intermittent in nature as peristalsis occurs

• Abdominal distension

• Vomiting

• Obstipation (inability to pass gas or stool)

• Localized tenderness

• High-pitched or absent bowel sounds (depending on extent of

obstruction)

• Tachycardia and hypotension in presence of dehydration or

peritOnitis

• Bloody stools

Management of intestinal obstructions includes any of the

followingJ'···:

• Insertion of a nasogastric tube

• Supportive management of functional etiologies (as able)

• Surgical resection of mechanical obstructions from adhesions,

necrosis, tUnlor, or unresolved inflammatOry lesions, particularly if

the obstruction is in the large intestine

• ColostOmy placement and eventual colostOmy closure (Colostomy closure is also referred to as colostomy lakedown.)

Intestinal Ischemia

Ischemia within the intestinal tract, also called ischemic colitis, can be

acute or chronic and result from many factors, such as thrombosis or

emboli to the superior mesenteric artery, intestinal strangulation,

chronic vascular insufficiency, hypotension, oral contraceptives,

SAIDs, and vasoconstrictors, such as vasopressin and dihydroergotamine. Methamphetamine and cocaine have vasoconstrictive properties that can also lead to intestinal ischemia. Significant ischemia that

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ACUTE CARE HANDBOOK FOR PHYSICAL THERAPISTS

is not managed in a timely manner can lead to intestinal necrosis or

gangrene and prove to be a life-threatening siruarion.J9.40.47

Signs and symptoms of intestinal ischemia include the

foliowingJ9•4o;

• Abdominal pam ranging from colicky pain to a steady severe

ache, depending on the severity of i chemia

• Nausea and vomiting

• Diarrhea or rectal bleeding

• Rebound tenderness, abdominal distention, and rigidity (with

necrosis)

• Tachycardia, hypotension, and fever (with necrosis)

Management of intestinal ischemia includes any of the

following"·47;

• Revascularizarion procedures, including balloon angiopiasty,

bypass grafting, embolectomy, and endarterectOmy

• Resection of necrotic segments with temporary colostomy or

ileostomy placement and subsequent reanasromosis of functional

segments as indicated

• Anti-infective agents

• Vasodilators or vasopressors (blood perfusion enhancement)

• Anticoagulation therapy

• i.v. fluid replacement

• Insertion of nasogastric tube

• Analgesic agents

Irritable Bowel Syndrome

Irritable bowel syndrome (ISS), also referred to as (I/nctio/wl bowel

disorder or spastic colon, is characterized by inconsistent motility of

the large bowel (i.e., constipation or diarrhea). Motility of the large

bowel can be affected by emotions; certain foods, such as milk products; neurohumoral agents; GI hormones; toxins; prostaglandins; and colon distention.J9•4o Recent findings now suggest that patients with