Identifying Gastrointestinal Conditions - NCLEX-PN

While Crohn's disease can affect any part of the alimentary canal, the small intestine, particularly the terminal ileum, is the most common site of serosal inflammation.

The characteristic histological alteration seen in ulcerative colitis is the crypt abscess, in which inflammation causes loss of goblet cells due to neutrophilic exudate in glandular lumens. Granulomas, thickened mucosa, and skip lesions are all seen in Crohn's disease.

Intestinal atresia is a malformation resulting in narrowing or absence of a portion of the intestine. Duodenal atresia is the most common type, followed by ileal atresia. Hirschsprung's disease is an issue of innervation in the large intestine that can result in narrowing due to contraction, but there is no structural malformation in the bowel itself. Malrotation and volvulus are often seen together when a part of the intestine does not anchor or turn correctly during formation (malrotation) and then becomes twisted around itself (volvulus), resulting in constriction and loss of function.

While an infant with Hirshsprung's disease may have vomiting and bloody stool, the most common sign is failure to pass meconium within 48 hours of delivery. Hirschsprung's disease, which is an absence of innervation to the large intestine, which results in narrowing and constriction of one part of the bowel and dilation of the preceding segment, can be diagnosed by biopsy of the distally narrowed segment of the bowel.

Intussusception occurs when part of the intestine folds into another section of intestine, much like a telescope. This results in sharp, crampy, or colicky abdominal pain, vomit of bile, and bloody red "currant jelly" stool. Black stool and "coffee ground" emesis are both symptoms of upper gastrointestinal bleeding (stomach, generally), while projectile vomiting may be associated with pyloric stenosis.

The most common location for diverticulitis is the sigmoid colon. This area generally has increased pressure as compared to the rest of the large intestine and is especially vulnerable to weakness in the muscle layers of the colon wall.

In congenital hypertrophic pyloric stenosis, the smooth muscle of the pylorus becomes thickened, decreasing the lumen size of the pylorus. This prevents food from passing out of the stomach and into the small intestine, resulting in vomiting which is often projectile and tends to be non-bilious. Intussusception may show vomiting, but the more obvious sign is bloody "currant jelly" stools. Infant gastroesophageal reflux disease (GERD) may result in frequent spitting up, but projectile vomiting is rare. Diverticulitis is generally a condition of the elderly and tends to present as abdominal pain with alterations in bowel function and mild fever.

Mallory–Weiss syndrome refers to bleeding from partial-thickness tears in the mucosa at the junction of the stomach and esophagus, often from trauma such as violent retching or coughing. This is compared to Boerhaave's syndrome, which is a full-thickness tear of the esophageal wall. Esophagitis is most commonly caused by gastroesophageal reflux disease (GERD) and does not present with bleeding. Barrett's esophagus refers to a type of metaplasia in the lower esophagus which is thought to be caused by chronic GERD.

Esophageal varices are most commonly seen in patients with cirrhosis due to portal hypertension. Gastroesophageal reflux disease (GERD) is associated with esophagitis and occasionally with metaplastic changes. Neither hiatal hernia nor achalasia are associated with esophageal varices.

Full-thickness (transmural) ulceration of the bowel wall occurs in Crohn's disease. Bowels may also show thickened walls, serosal adhesions, and loss of the regular folds.

In ulcerative colitis, ulceration is restricted to the gut mucosa. Celiac disease results in blunting of intestinal villi, but does not cause ulceration in any form. Irritable bowel syndrome, or IBS, is considered a functional disease as it results in no known pathological tissue changes.

The treatment for peptic ulcer disease when the bacterium H. pylori is found to be present has several treatment strategies. These strategies include a triple drug therapy consisting of a proton pump inhibitor, amoxicillin and clarithromycin. This combination of drugs should be continued for 7-14 days, 2 months is not the course of treatment. All other statements are consistent with proper teaching of causative factors associated with peptic ulcer disease.

The patient is displaying symptoms that could indicate a paralytic ileus. A paralytic ileus is a blockage of the intestine that may result after surgery, most commonly abdominal surgery. During an ileus, the intestine cannot move food through the bowel. A patient with this condition will not have bowel sounds. Constipation, nausea, and vomiting are all considered symptoms of an ileus.

Older adults are at high risk for the development of side effects related to medication use. Anti-emetics are commonly administered medications and may cause confusion, especially in older adults.

Ulcerative colitis has a usual age of onset from 20-30 and 50-80 years old. Patients with UC have frequent fatty stools with occasional rectal bleeding and abdominal pain after eating. Nurses who care for patients with UC must consider possible intestinal obstruction and fistula formation in these patients. Crohn’s disease has a usual age of onset from young adults to middle aged (30-50 years old). Patients with Crohn’s disease do not have fatty stools but do have common rectal bleeding that may lead to hemorrhage. These patients experience pain before defecating and will have 10-20 liquid (usually bloody) stools per day. Nurses who care for patients with Crohn’s disease should consider possible abscess formation and arthritis. Both UC and Crohn’s disease present with weight loss, anemia, and dehydration due to ineffective nutritional absorption through the intestinal tract.

The liver generally responds to injury in the following ways: inflammation, necrosis or apoptosis, degeneration leading to accumulation of intracellular deposits, fibrosis, and regeneration. Some of these, such as inflammation and mild degeneration, are reversible. Other changes, such as severe degeneration and fibrosis, may be permanent.

Ballooning degeneration is a form of hepatocellular apoptosis (rather than necrosis) in which hepatocytes swell and begin to show irregularly clumped cytoplasmic organelles and large clear spaces. It is a severe condition often seen with viral hepatitis or steatohepatitis. It is distinct from fibrotic changes, in which depositions of collagen fibers are seen on histology. Ascites is a collection of fluid in the peritoneal cavity, rather than a histological feature.

The most likely cause of this patient's diarrhea is Clostridium difficile, also known as "C. diff."

Clostridium difficile typically causes watery, non-bloody, mucoid diarrhea, associated with fever and abdominal pain, most commonly in patients who have completed a recent course of antibiotics. In the past, it was thought that clindamycin was the most frequent antibiotic-related cause of C. difficile, but recent studies have shown that other classes of antiobiotics, including cephalosporins, are associated with comparable rates of C. difficile diarrhea. In this patient, the characteristics of her diarrhea, associated sypmtoms, and recent antibiotic exposure are most consistent with C. difficile as the cause of her diarrhea.

Escherichia coli exists in multiple subtypes, but often is associated with bloody diarrhea after eating undercooked red meats (EHEC diarrhea), or watery diarrhea after traveling to a foreign, undeveloped country (ETEC diarrhea). This patient's history is not consistent with E. coli infection.

Salmonella and Shigella diarrhea are each typically bloody. This patient's diarrhea is non-bloody.

Cryptosporidium parvum diarrhea is often watery, as is the case in this patient, but it frequently occurs in immunosuppressed patients, is typically not mucoid, and does not have a known temporal association with taking antibiotics, as does C. difficile.

The correct answer is "Try taking the pills with a full glass of water."

The concept tested by this question is pill esophagitis. Pill esophagitis is an irritation of the esophagus that can occur after a patient takes certain medications orally. Pill esophagitis is caused both in part by local, direct damage to the esophageal mucosal lining from the pill itself, as well as from (depending on the particular drug) the systemic actions of the drug. In this patient's case, he takes ibuprofen, which can both damage the esophagus lining directly, and also predispose to poor mucosal repair from its systemic effects.

There are a number of interventions to remediate pill esophagitis. If the medication can be changed to an equivalent drug that has less of a known propensity to cause pill esophagitis, that is a valid option. In addition, as in this case, you can encourage the patient to take the pill with a full glass of water, as this helps increase the odds of the pill traveling the full distance of the esophagus to the stomach, and not getting caught in the esophagus, causing localized damage and esophagitis symptoms.

Taking the pills while lying down would be an inappropriate intervention, as this increases the risk of the pill getting stuck in the esophagus, causing localized esophagitis symptoms. The same reasoning applies for taking the pill right before lying down for bed.

Taking the pills without any water would also decrease the odds of the pill fully traveling down the esophagus to the stomach, and therefore increases the odds of experiencing pill esophagitis symptoms.

Requesting more of the pills without addressing how the patient is taking the pills would be inappropriate, as they appear to be inciting the esophagitis pain.

The correct answer choice is "post-operative ileus." This answer is correct because in the presented scenario, the patient is just 36 hours removed from a total abdominal hysterectomy, which is an invasive abdominal surgery. During a hysterectomy, the patient typically receives inhaled anesthesia, as well as opioid pain medications, which each individually can result in a post-operative ileus. Furthermore, given that there is manipulation of abdominal organs in accessing the uterus, simple mechanical manipulation of the bowels during surgery can be enough to result in a post-operative ileus. For each of these reasons, post-operative ileus is a common occurrence, and is the most likely cause of this patient's lack of passing of flatus or feces.

There is no reason to think that this patient received post-operative amphetamines. Furthermore, if the patient did receive amphetamines, that would likely stimulate the digestive tract, rather than inhibit its activity.

Neither bacterial, viral, nor fungal infections would be likely causes of lack of flatus or feces passage following a surgery. These infections would be more likely to cause loose stools/diarrhea, rather than an ileus.