Digestion and

Bowel Elimination
Mark Sumalinog
 Effects of Aging on G.I. Health

• decreasing taste sensation

• saliva production decreases- swallowing is difficult
• presbyesophagus- degenerative change in the smooth
muscle lining of the lower esophagus; weaker sphincter
• Esophageal and stomach motility decreases- food can
remain for longer period of time; risk for aspiration and
indigestion
• decreased elasticity of the stomach- reduced amount of
food
 Effects of Aging on G.I. Health

• increase gastric pH- gastric irritation

• reduced pepsin production- reduced absorption of protein
• reduced HCl- reduced calcium, iron, folic acid and vitamin B12
absorption
• fewer cells on the absorbing surface of the intestinal wall
• constipation- slower peristaltic activity, reduced food and fluid
intake, and low fiber diet
• unnoticed bowel movement- decreased sensory perception
 Effects of Aging on G.I. Health

• bile salts synthesis decreases - gallstone development

• pancreas- fibrosis, atrophy, fatty acid deposits;
intolerance to fatty food
• liver- decrease in size but function remains the same
 Promote G.I. Health

• good dental hygiene; regular visit to the dentist

• proper quantity and quality of food
• good fluid intake
• diet rich in fruits and vegetables
• activity
• establishment of regular time for bowel movement
• dietary fiber: 20-35 g/day; if fiber intake has been low, the
amount should be gradually increased (to avoid GI
disturbances)
 Promote G.I. Health

• plenty of fluids to accompany increased fiber intake- to

provide opportunity for full bowel elimination
 Dry Mouth (Xerostomia)

• reduced saliva (saliva lubricates soft tissues, assist in re-

mineralizing the teeth, promoting taste sensation and
helps the oral cavity control bacteria and fungal growth)
• Medications (risk): diuretics, anti-hypertensives, anti-
inflammatories and antidepressants
• Sjogren’s syndrome, chronic inflammatory disorder
• Mouth breathing and altered cognition
 Dry Mouth (Xerostomia)

• frequent oral hygiene: reduce dental diseases

• sipping water; sucking sugarless candy and chewing gum
are also proven effective
• Salivart Synthetic Saliva (Saliva substitutes available as
gels and rinses)
 Dental problems

• poor condition of teeth can restrict food intake-

constipation and malnutrition
• dental examination can be an instrument to detect and
prevent many problems that affect other body systems
• leads to disturbed body image, social isolation, poor
appetite
• financial limitations prevent many older adults from
seeking dental attention
 Dental problems

• older adults think that having dentures eliminate the need

for dental visits
• regular dental check-ups; explaining serious diseases can
be detected by the dentist
• help patients identify free or inexpensive dental clinics
• topical fluoride treatments
• inform dentists about health problems and
medications taken to modify certain dental
procedures
 Dental problems

• caused by altered taste sensation, a poor diet, excessive

intake of sweets
• deficiencies of vitamin B complex and calcium, hormonal
imbalances, hyperparathyroidism, diabetes, osteomalacia,
Cushing disease and syphilis
• phenytoin (gingivitis), anti-histamines and anti-
psychotics (dry mouth)
• aging- loss of tooth enamel leads to irritation of deeper
dental tissues
 Dental problems

• benign neoplastic lesions develop more frequently than

malignant ones
• cancer of the oral cavity and moniliasis (leukemia and
diabetes) common in men
• periodontal disease, which damages the soft tissue
surrounding the teeth and supporting bones, is a major
cause of tooth loss
• dental carries
 Dental problems

• good oral hygiene

• teeth, gums, and tongue should be brushed regularly
• trauma to the buccal mucosa should be avoided (thinner
and less vascular with age)
 Dysphagia
• swallowing depends on a complex mechanism involving
cranial nerves, and the muscles of the mouth, face,
pharynx, and esophagus
• GERD and stroke
• oropharyngeal (difficulty from the mouth to the pharynx
and esophagus); more common in persons with
neurologic damage
• esophageal (difficulty with the transfer of food down the
esophagus); more common in persons with motility
disorders, sphincter abnormalities, or mechanical
obstruction such as strictures
 Dysphagia

• assessment: when the problem began; what other

symptoms accompanied dysphagia; what types of food
trigger the symptoms; is it intermittent or present with
every meal
• observe food intake
• refer to a speech language pathologist
• goal: prevent aspiration and promotion of adequate
nutritional status
 Dysphagia

• soft diet and thickened liquids to facilitate swallowing

• eat in upright position, ingesting small bites and in an
unhurried manner
• easily accessible suction machine is beneficial in the
event of choking
• monitor food intake and weight
 Hiatal Hernia

• greater incidence in women, over age of 50

• 2 types- sliding and rolling
• sliding (axial)
– most common; when the junction of the espohagus and
stomach slides through the diaphragm; px with GERD
• rolling (paraesophageal)
– fundus and greater curvature of the stomach roll up through
the diaphragm
 Hiatal Hernia

• sx: heartburn, dysphagia, belching, vomiting and

regurgitation; bleeding may also occur
• dx: barium swallow and esophagoscopy
• ttt:
– weight reduction (obese); bland diet; use of antacids; small
frequent feedings; H2 blocker (ranitidine, cimetidine) and PPI
– eating before bedtime is discouraged
– sleep in recumbent position
 Esophageal Cancer

• most common- squamous cell and adenocarcinoma

• higher incidence in men; 50-70 yrs old
• hx of alcoholism and heavy smoking; poor oral hygiene
• Barett's esophagus (the lining of the esophagus is
replaced by a lining usually found in the intestines)- risk
for adenocarcinoma
• sx: dysphagia, weight loss, excessive salivation, thirst,
hiccups, anemia and chronic bleeding
 Esophageal Cancer

• sx not recognized until cancer is advanced, contributing to

poor prognosis
• dx: barium swallow, esophagoscopy, biopsy
• Ttt:
– surgical resection
– radiation, chemotherapy
– laser therapy
– photodynamic therapy(the use of photosensitizing agents,
along with light, to kill cancer cells)
 Peptic Ulcer

• stress, diet, genetic predisposition

• complication of COPD
• medications: aspirin, colchicine and adrenal
corticosteroids
• smoking, heavy drinking, caffeine, H. Pylori infection
• sx: pain, bleeding, obstruction, perforation
• ttt: antacid therapy (watch for constipation or diarrhea)
• pyloric obstruction- watch for dehydration, peritonitis,
hemorrhage and shock
 Cancer of the Stomach
• increases with age; 50-70 yo
• men, poor, African American, Asian, Hispanics
• Adenocarcinoma accounts most of the malignancies
• sx: anorexia, epigastric pain, weight loss, and anemia (symptoms
can be mistaken for indigestion problems)
• bleeding and hepatomegaly may occur; pelvic metastasis may
also develop
• dx: barium swallow, gastroscopy and biopsy
• ttt: partial or total gastrectomy
• diet: low in red meat and high in antioxidants (prevent this cancer)
 Diverticular Disease

• multiple pouches of the intestinal mucosa in the

weakened muscular wall of the large bowel
• risk: chronic constipation, obesity, hiatal hernia, atrophy of
the intestinal wall muscles with aging; low fiber diet
• sx: slight bleeding, constipation, diarrhea, or both;
tenderness upon palpation of the LUQ
• dx: barium enema,
• ttt: surgery not performed unless bleeding develops;
increase in dietary fiber intake, weight reduction and avoid
constipation
 Diverticular Disease

• bowel contents may accumulate in the diverticula and

decompose- infection and inflammation (diverticulitis)
• diverticulosis-> diverticulitis (older adult)
• Over-eating, straining during a bowel movmt., alcohol and
irritating food
• abrupt onset of pain over the LLQ (similar to appendicitis)
but over the sigmoid colon
• fistula to the vagina, bladder, colon or intestine may
develop
 Colorectal Cancer

• rectum and sigmoid colon most frequent sites

• sx: bloody stools, change in bowel pattern, anorexia,
nausea, pain over affected region, anemia
• digital rectal exam (DRE) to detect a carcinoma of the
large bowel and rectum
• dx: fecal occult blood for early detection; standard-
barium enema, sigmoidoscopy and biopsy
• ttt: surgical resection
 Colorectal Cancer

• colostomy
– major adjustments and threat to self-concept
– separates them from the society (having it is not normal)
– socialization is impaired
– care for colostomy is affected by: weakness, arthritic fingers,
slower movement, poor eyesight
– increased dependence
– continued follow-up is beneficial to assess the patient's
changing abilities to do self-care
– provide support and reassurance
 Chronic Constipation
• Factors: inactive lifestyle, low fiber intake, depression, laxative
abuse, medications (opiates, sedatives, and Aluminum hydroxide
gels), dulled sensation, failure to allow sufficient time for complete
emptying of the bowel

• diet high in fiber, regular activity, regular time for bowel elimination
(morning tend to be the best time to empty their bowels)

• safe laxative use to prevent laxative dependence/ abuse

 Chronic Constipation

• diarrhea resulting from laxative abuse may cause

dehydration
• dandelion root, cascara sagrada, senna, rhubarb are
herbs that stimulate bowel movement
• hospital: elimination charts are beneficial
• chronic constipation that does not respond to treatment
may need further evaluation to identify underlying cause
 Flatulence

• caused by constipation, irregular bowel movements, certain food

(high fiber food), poor neuromuscular control of the anal sphincter
• achieving a regular bowel pattern, avoid flatus producing food
(cabbage, cucumbers, broccoli, cauliflower)
• sit upright after meals (to allow gas to climb up the fundus and be
expelled)
• increased activity, knee chest position to relieve discomfort
• flatus bag- prevents air from entering the rectum
 Intestinal Obstruction

• cause:
– partial or incomplete impairment of flow of intestinal
contents in the large intestine due to cancer of the colon;
– adhesions and hernias (small intestine);
– diverticulitis, ulcerative colitis, hypokalemia, vascular problems
and paralytic ileus
 Intestinal Obstruction

• sx: depending on the site

– small bowel obstruction : upper and mid abdominal pain in
rhythmic recurring waves related to the small intestines attempt
to push the contents through the obstruction; vomiting may
occur

– obstruction occurring past the ileum cause abdominal

distention that the raised diaphragm can inhibit respiration;
vomiting is severe (semi-digested food and later contains bile
and is more watery)
 Intestinal Obstruction
– obstruction of the colon: lower abdominal pain, altered bowel
habits, distention and a sensation of the need to defecate;
vomiting is not usual (occurs only when the distention
reaches the small intestine)
• nurse:
– review symptoms carefully and assess for bowel sounds (high
pitched peristaltic rushes); absent (bowel has been significantly
damaged)
– timely intervention is essential to prevent bowel strangulation
and serious complications
 Intestinal Obstruction

• xrays and blood evaluation

• intestinal intubation is the major treatment (decompress
the bowel and allow the obstruction to be broken)
• if medical management is unsuccessful, surgery is
required
• fluid and electrolyte balance is restored or maintained
 Fecal Impaction

• prevent constipation
• observing the frequency and character of bowel
movements may aid in detecting the development of an
impaction
• bowel elimination record/ chart
• indications: distended rectum, abdominal and rectal
discomfort, oozing of fecal material around the
impaction, palpable hard fecal mass and fever
 Fecal Impaction

• enema, usually oil retention, is prescribed

• manual removal of fecal impaction with a lubricated
gloved finger
• INJECT 50 ML OF HYDROGEN PEROXIDE through a
rectal tube can break the impaction as the peroxide
foams
 Fecal Incontinence

• Involuntary defecation; inability to control the passage of the stool

• associated with fecal impaction in older adults who are
institutionalized or physically or cognitively impaired
• initial step: assess the presence of impaction
• if not present, assess for other causes
• causes: decreased contractile strength, impaired automaticity of
the puborectal and external anal sphincter (age related muscle
weakness or injury to pudendal nerve); reduced reservoir capacity
 Fecal Incontinence

• dx: proctosigmoidoscopy, proctography, anorectal

manometry
• bowel retraining, drugs, surgery or biofeedback
 Acute Appendicitis

• severe pain that occurs in younger persons may be

absent in older adults
• fever may be minimal
• leukocytosis may be absent
• delayed diagnosis: greater complications and mortality
• Prompt surgery will improve prognosis
 Cancer of the Pancreas
• difficult to detect until it reached advanced stage
• sx: anorexia, weakness, weight loss, and wasting
• other sx: dyspepsia, belching, nausea, vomiting, diarrhea,
constipation, and obstructive jaundice
• fever may or may not be present
• epigastric pain radiating to the back (relieved when the
persons leans back and worsens when in recumbent
position)
• ttt: surgery
• prognosis is poor because disease is usually advanced when
detected
 Biliary Tract Disorder

• cholelithiasis (gallstones); more common in women

• pain is the primary symptoms
• ttt: ESWL or Extracorporeal Shockwave Lithotripsy
• outcomes: obstruction, inflammation and infection
requiring monitoring
 Biliary Tract Disorder

• cancer of the gallbladder; common in women

• pain in the RUQ, anorexia, n/v, weight loss, jaundice,
weakness and constipation
• ttt: surgery
• prognosis is poor
 Digestion and
Bowel Elimination
Mark Sumalinog