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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.