11.15 Other Gastrointestinal Disorders

Overviews of other common gastrointestinal disorders are discussed in this section.

Hepatitis

The term hepatitis means inflammation of the liver. This disorder commonly results from viruses, leading to hepatitis A, B, or C. Hepatitis D and E also exist, but are rarer than hepatitis A thru C. Hepatitis can also be caused by the use of drugs or alcohol and is also linked to a variety of autoimmune disorders.^[1]

Hepatitis can be an acute or a chronic condition. When it lasts for six months or less, it is considered acute, and when it lasts over six months, it is considered chronic. The severity of hepatitis ranges from mild to severe based on the source of the inflammation.^[2]

Hepatitis A is commonly transmitted via the fecal to oral route and is common in places where there is poor sanitation. Hepatitis B and C are transmitted via contact with infected body fluids via contaminated blood transfusions, sharing of needles, or other parenteral measures. Hepatitis B and C can also be transmitted sexually and via pregnancy/childbirth. The incubation period for viral hepatitis ranges from four to twelve weeks, depending on the specific virus. Hepatitis A is usually an acute condition, but hepatitis B and C have the potential to become chronic and even lead to liver cancer or other complications.^[3]

Alcoholic hepatitis is liver inflammation that is caused by excessive alcohol use. The breakdown of ethanol can lead to death of liver cells, but the exact mechanism of action is unclear. Autoimmune hepatitis is when the body develops auto-antibodies that attack the liver, but the exact pathophysiology is not well understood. This can be triggered by exposure to certain drugs or viruses.^[4]

Regardless of the causes of hepatitis, the signs and symptoms are similar. Common early signs and symptoms are loss of appetite, nausea, vomiting, and fatigue or asymptomatic. As the disorder progresses, jaundice, pain in the right upper quadrant, an enlarged liver, light-colored stools, and dark-colored urine may appear. In severe cases of autoimmune and alcoholic hepatitis, clients may also have ascites (excessive fluid buildup in the abdomen) and hepatic encephalopathy (mental status changes related to impaired liver function due to buildup of toxins, such as ammonia).^[5]

Lab values that may be altered in hepatitis are liver enzymes, bilirubin, coagulation labs, and ammonia levels. Liver enzymes and bilirubin levels may be elevated. Coagulation labs such as prothrombin time (PT) and internalized normalized ratio (INR) will be increased due to the liver’s role in blood clotting. Ammonia levels can be elevated if hepatic encephalopathy is present.^[6]

To diagnose viral hepatitis, blood tests can be run that can detect the presence of antibodies to hepatitis viruses. Liver biopsies can also be done to confirm a diagnosis and assess the extent of the disease. There are also a variety of blood tests that can be done to diagnose autoimmune hepatitis, but the gold standard is a liver biopsy. Liver inflammation that is related to alcohol use does not require a diagnostic workup if a history of alcohol abuse is present.^[7]

Hepatitis treatment consists of supportive care for acute viral cases. Chronic cases can be treated with antiviral medications and medications that suppress the immune system, but these medications can have serious side effects that must be monitored.^[8]

Autoimmune hepatitis can be managed with steroids and/or drugs that suppress the immune system. Liver transplantation is also an option for those who experience liver failure.^[9]

Those who suffer from alcoholic hepatitis should abstain from the use of alcohol and receive supportive care. Short-term steroid administration may also be beneficial. Liver transplantation is also an option, but only in those who have been alcohol free for six months or more.^[10]

Lastly, there are vaccines that are available to prevent the transmission of hepatitis A and B. Hepatitis A vaccines should be offered to those traveling to endemic areas or at high risk for contracting the disorder. Hepatitis B vaccine is part of the newborn vaccination schedule and should also be taken by those who are at risk for blood exposure, such as health care workers.^[11]

Liver Cirrhosis

Liver cirrhosis occurs due to chronic liver damage and is characterized by the development of liver nodules and liver fibrosis (stiffening/scarring of the liver). This chronic liver damage can be related to viruses like hepatitis C, toxic substances like drugs or alcohol, or autoimmune conditions. There is also a hereditary link.^[12],[13]

When exposed to injurious substances, cells in the liver react by depositing excess collagen, which leads to fibrosis. Initially, this fibrosis does not result in loss of liver function. However, as the exposure is repeated over time, the majority of the liver will become fibrosed, and loss of function results. Ultimately, this leads to portal hypertension or elevated pressures in the blood vessels of the liver. Due to the elevated pressure, the body compensates by diverting blood to other veins. This increase in blood flow weakens these vessels and makes them prone to injury and bleeding.^[14],[15]

Clients with liver cirrhosis may be asymptomatic, and the disorder may only be discovered incidentally. Others may experience ascites, jaundice, hepatic encephalopathy, bleeding of varices (enlarged veins in the esophagus that occur due to portal hypertension) and enlarged liver and/or spleen. As cirrhosis and portal hypertension continue to progress, the effects are widespread and affect multiple organs of the body. Those with liver cirrhosis are also at an increased risk for liver cancer.^[16],[17]

Analysis of labs will show elevation of liver enzymes and prothrombin time. Albumin levels will also be decreased, as this protein is made in the liver. Decreased red blood cells, white blood cells, and platelets may also be seen. Liver cirrhosis can be evaluated with an ultrasound, CT scan, or MRI, but the best diagnostic tool is a liver biopsy. Other tests may be done to evaluate for the specific cause of liver cirrhosis.^[18],[19]

Cirrhosis can not be reversed, so treatment is focused on preventing further injury to the liver. Other treatments may also focus on the specific cause of liver cirrhosis. Liver transplantation may also be an option for some clients.^[20],[21]

Pancreatitis

Pancreatitis is inflammation of the pancreas, and it can be an acute or chronic condition. Although there are a variety of causes of acute pancreatitis, the most common causes are the presence of gallstones and excess alcohol use. Chronic pancreatitis is most commonly caused by alcohol abuse.^[22]

In acute pancreatitis caused by gallstones, the pancreatic duct is obstructed and cannot release digestive enzymes. This leads to autodigestion, a process in which the enzymes of the pancreas digest pancreatic tissue, as well as inflammation. Alcohol use can lead to acute pancreatitis due to the toxic effect of alcohol on pancreatic tissues. Chronic pancreatitis occurs when the pancreas is repeatedly attacked, leading to scarring and pancreatic hypofunctioning.^[23]

Common signs of acute pancreatitis are epigastric abdominal pain that spreads to the back, nausea, and vomiting. Jaundice may be present if the pancreatitis is caused by gallstones, and severe pancreatitis may lead to changes in mental status. Those with chronic pancreatitis may have nausea, vomiting, abdominal pain, weight loss, and steatorrhea. There is also the potential for the development of diabetes due to pancreatic damage.^[24]

Acute pancreatitis can be diagnosed by the presence of elevated serum lipase levels. These levels may be increased or normal in those with chronic pancreatitis. Imaging, such as a CT scan, MRI or MRCP, may also be done.^[25]

Treatment of acute pancreatitis consists of IV fluids, analgesics, and diet modification. The client can take food by mouth if their pain is well-managed, but parenteral nutrition may be needed in severe cases. If acute pancreatitis is caused by the presence of gallstones, an ERCP and/or a cholecystectomy may be needed. Clients with chronic pancreatitis will require pain management, a low-fat diet, and education on alcohol abstinence and potentially exogenous pancreatic enzymes.^[26]

Colon Cancer

Colon cancer is cancer of the colon or rectum and is one of the top causes of death in the United States. Risk factors for colon cancer are a family history, the presence of colon polyps, a history of inflammatory bowel disease, prior radiation to the abdomen, obesity, tobacco or alcohol use, and the intake of red or processed meat.^[28],[29]

Colon cancer forms after a number of genetic mutations result in cellular changes in the colon. Once colon cancer develops, it can be staged using the TNM system.^[30],[31] For more information on this system of staging, please visit the “Malignancy and Autoimmune Alterations” chapter of this textbook.

Sometimes colon cancer is found incidentally during a colonoscopy or at-home colon cancer screening. A popular at-home screening is Cologuard, which looks for abnormal DNA and blood in a stool sample. Others may have symptoms such as blood in the stool, abdominal pain, anemia, and changes in bowel movements that prompt them to seek medical care. Colon cancer commonly spreads to the liver, lungs, and/or lymph nodes. Clients with metastasis may have additional signs and symptoms.^[32],[33]

A definitive diagnosis of colon cancer requires a colonoscopy with a biopsy, but it could also be detected with a barium enema, CT scan, or MRI. A CEA test, a tumor marker blood test, may also be elevated with colon cancer. However, this test is used to monitor treatment response, not to diagnose.^[34],[35]

Colon cancer can be treated with surgical removal of the cancerous area and affected lymph nodes, chemotherapy, immunotherapy, or other biologic agents. If the entire colon must be removed, the client will end up with a colostomy.^[36],[37] For more information on nursing care of clients with cancer, please visit the “Malignancy and Autoimmune Alterations” chapter.