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NURSING MANAGEMENT OF GIT PROBLEMS ORAL AND ESOPHAGEAL DISORDERS DISORDERS OF THE SALIVARY GLANDS •The salivary glands consist of the parotid glands, one on each side of the face below the ear; the submandibular and sublingual glands, both in the floor of the mouth; and the buccal gland beneath the lips.

•About 1,200 ml of saliva are produced daily. •Primary functions are lubrication, protection against harmful bacteria, and digestion.

PAROTITIS •Inflammation of the parotid gland •Mumps (epidemic parotitis) •Elderly, acutely ill or debilitated people with decreased salivary flow from general dehydration or medications are at high risk for parotitis.

•Onset is sudden, with an exacerbation both of fever and the symptoms of the primary condition. •Gland swells and becomes tense and tender, with pain in the ear, and difficulty in swallowing. Nursing Management

•Maintain adequate nutritional and fluid intake and good oral hygiene. •Discontinue medications that can diminish salivation (tranquilizers and diuretics). •Antibiotics may be prescribed in bacterial parotitis. •Analgesics to control pain. •Parotidectomy in case of persistent inflammation NEOPLASMS •Relatively uncommon in the salivary glands. •Tumors occur more often in the parotid gland. •Incidence is the same in men and women. •Risk factors include prior exposure to radiation to the head and neck. •Diagnosis is based on the health history and physical examination and the results of aspiration biopsy. Nursing Management •Common procedure involves partial excision of the gland, along with all of the tumor and a wide margin of the surrounding tissue. •Dissection is careful to preserve CN VII

•If lesion is malignant, RT may follow surgery. •Chemotherapy is usually used for palliative purposes. 1

•Local recurrences are common, and the recurrent growth usually is more aggressive than the original.

CANCERS OF THE ORAL CAVITY •Cancers of the oral cavity, which can occur in any part of the mouth or throat, are curable if discovered early. •Associated with the use of alcohol and tobacco. •Chronic irritation by a warm pipesteam or prolonged exposure to the sun and wind may predispose a person to lip cancer.

•Predisposing factors for other oral cancers are exposure to tobacco, ingestion of alcohol, dietary deficiency, and ingestion of smoked meats.

Pathophysiology

•Malignancies are usually squamous cell cancers. •Any area of the oropharynx can be a site for malignant growths. •Lips, lateral aspects of the tongue and the floor of the mouth are commonly affected. Manifestations

•Many oral cancers produce few or no symptoms in the early stages. •Later, the most frequent symptom is a painless sore or mass that will not heal. •A typical lesion is a painless, indurated ulcer with raised edges. •Tissue from any ulcer of the oral cavity that does not heal in 2 weeks should be examined through biopsy. •As the cancer progresses, the patient may complain of tenderness, difficulty in chewing, swallowing or speaking; coughing of blood-tinged sputum; or enlarged cervical lymph nodes.

Medical Management

•Management varies with the nature of the lesion, preference of the physician, and patient choice. •Surgical resection •Radiation therapy •Chemotherapy •Combination therapy Nursing Management

•Assess the patient’s nutritional status preoperatively and a dietary consultation may be necessary. •Patient may require enteral or parenteral feedings before and after surgery to maintain adequate nutrition. •Postoperatively, assess the patient for a patent airway. NURSING PROCESS: Conditions of the Oral Cavity •Assessment Lips 2

Gums Tongue •Nursing Diagnoses •Planning and Goals Improved conditions of the oral mucous membrane Improved nutritional intake Attainment of a positive self-image Relief of pain Identification of alternative communication methods Prevention of infection

•Nursing interventions Promoting mouth care Ensuring adequate food and fluid intake Supporting a positive self-image Minimizing pain and discomfort Promoting effective communication Preventing infection Promoting home and community-based care

•Evaluation

DISORDERS OF THE ESOPHAGUS DYSPHAGIA •The most common symptom of esophageal disease. •Ranges from an uncomfortable feeling that a bolus of food is caught in the upper esophagus to acute pain on swallowing (odynophagia).

ACHALASIA •Absent or ineffective peristalsis of the distal esophagus, accompanied by failure of the esophageal sphincter to relax in response to swallowing.

•Primary symptom is difficulty of swallowing both liquids and solids, regurgitation of food either spontaneously or intentionally, chest pain and heart burn (pyrosis), and secondary pulmonary complications from aspiration of gastric contents.

•X-rays show esophageal dilatation above the narrowing at the gastroesophageal junction.

•Diagnosis is confirmed by manometry, a process in which esophageal pressure is measured by a radiologist or 3

gastroenterologist.

Nursing Management

•Eat slowly and drink fluids with meals •Calcium channel blockers and nitrates •Botox injection to quadrants of the esophagus •Pneumatic or forceful dilation or surgical separation of the muscle fibers. •Surgical treatment by esophagomyotomy in which the esophageal muscle fibers are separated to relieve the lower esophageal stricture.

•Patients with achalasia have a slightly higher incidence of esophageal cancer. DIFFUSE SPASM •Motor disorder of the esophagus •Unknown cause •Stressful situation – trigger •Woman > Man •Common to middle age Clinical Manifestations

•Dysphagia •Odynophagia •Chest pain similar to coronary artery spasm Diagnostic Examination

•Esophageal manometry •X-ray •Barium studies on EGD Management

•Sedative and nitrates – for pain •Calcium channel blocker •Small frequent feeding and soft diet •Dilatation by bougienage

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DIVERTICULITIS •Outpouching of muscosa and submucosa

•

Occurs in 3 areas of esophagus

•Paryngoesophageal or upper area of esophagus (Zenker’s Diverticulitis) – Most common, occurs in >60 years old

•Midesophaeal (Uncommon) –less acute, does not require surgery

•Epiphrenic or lower area or border of esophagus –lower esophageal sphincter dysfuction •Intramurally – occurrence of small diverticulitis associated with stricture of upper esophagus Clinical Manifestations

•Dysphagia •Fullness in the neck •Belching •regurgitation of undigested food •Gargling sound after eating •Halitosis •One third of patients of epiphrenic type – Asymptomatic •Two-third of patients have dysphagia and chest pain Diagnostic Examination 5

•Barium swallow •Manometric Studies – done in epiphrenic type to rule out motor disorder •Contraindicated exams •Esophagoscope •Blind insertion of NGT Treatment

•Surgical removal of diverticula •Myotomy

HIATAL HERNIA •The esophagus enters the abdomen through an opening in the diaphragm and empties at its lower end into the upper part of the stomach.

•Normally, the opening in the diaphragm encircles the esophagus tightly, and the stomach lies completely within the abdomen.

•In hiatal hernia, the opening in the diaphragm through which the esophagus passes becomes enlarged, and part of the upper stomach tends to move up into the lower portion of the thorax.

•Protrusion of the esophagus into the diaphragm thru an opening

•Two types- Sliding hiatal hernia •( most common) and Axial hiatal hernia •Occurs most often in women than in men. •Classified as either sliding or paraesophageal. Clinical manifestations

•Pyrosis •Regurgitation and dysphagia •Fullness after eating •Complications of hemorrhage, obstruction and strangulation can occur with any type of hernia. Assessment 1. Heartburn 6

2. Regurgitation 3. Dysphagia 4. 50%- without symptoms

Diagnosis

•Diagnosis is confirmed by x-ray studies, barium swallow and fluoroscopy. Management

•Frequent small feedings •Advise patient not to recline for 1 hour after eating to prevent reflux or movement of the hernia, and to elevate the head of the bed on 4- to 8-inch blocks to prevent the hernia from sliding upward.

•Surgery is indicated in about 15% of patients Nursing Interventions 1. Provide small frequent feedings 2. AVOID supine position for 1 hour after eating 3. Elevate the head of the bed on 8-inch block 4. Provide pre-op and post-op care

ESOPHAGEAL VARICES •Dilation and tortuosity of the submucosal veins in the distal esophagus

•ETIOLOGY: commonly caused by PORTAL hypertension secondary to liver cirrhosis

•This is an Emergency condition!

Assessment 1. Hematemesis 2. Melena 3. Ascites 4. Jaundice 5. hepatomegaly/splenomegaly

•Signs of Shock- tachycardia, hypotension, tachypnea, cold clammy skin, narrowed pulse pressure Diagnostic Procedure

•Esophagoscopy

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Nursing Interventions 1. Monitor VS strictly. Note for signs of shock 2. Monitor for LOC 3. Maintain NPO 4. Monitor blood studies 5. Administer O2 6. Prepare for blood transfusion 7. Prepare to administer Vasopressin and Nitroglycerin 8. Assist in NGT and Sengstaken-Blakemore tube insertion for balloon tamponade 9. Prepare to assist in surgical management:

•Endoscopic sclerotherapy •Variceal ligation •Shunt procedures

PERFORATION •The esophagus is not an uncommon site of injury. •Perforation may result from stab or bullet wounds of the neck or chest, trauma from motor vehicle crash, caustic injury from a chemical burn, or inadvertent puncture by surgical instrumentation.

Clinical Manifestations

•Persistent pain followed by dysphagia •Infection, fever, leukocytosis and severe hypotension •Signs of pneumothorax Diagnostic Procedure

•Diagnostic x-ray studies and fluoroscopy are used to identify the site of the injury. Management

•Broad-spectrum antibiotic therapy •Suction by NGT insertion to reduce amount of gastric juice. •NPO; parenteral nutrition •Surgery may be necessary to close the wound •Post-operative nursing management FOREIGN BODIES •Many swallowed foreign bodies pass through the GIT without the need for medical intervention. •Some swallowed foreign bodies (dentures, fish bones, pins, small batteries, items containing mercury or lead) may injure the esophagus or obstruct its lumen and must be removed.

•Pain and dysphagia may be present, and dyspnea may occur as a result of pressure on the trachea. •Foreign body may be identified by x-ray film. 8

•Glucagon may be injected intramuscularly. •Endoscopy to remove the impacting food or object from the esophagus. •Sodium bicarbonate + tartaric acid may be used to increase intraluminal pressure by the formation of gas. Caution must be used because of the risk of perforation.

CHEMICAL BURNS •May be caused by undissolved medications in the esophagus, or by ingestion of caustic agents like strong acids and bases.

•May be intentional or accidental. •Patient is usually emotionally distraught as well as in acute physical pain.

•The patient may be profoundly toxic, febrile, and in shock. •Esophagoscopy and barium swallow are performed as soon as possible.

•Vomiting and gastric lavage are avoided to prevent further exposure of the esophagus to the caustic agent.

•Corticosteroids? •Antibiotics?

•Nutritional support via enteral or parenteral feeding •Prevent or manage strictures of the esophagus. •Dilation by bougienage •Surgical management for strictures that do not respond to dilation. •Reconstruction may be accomplished by esophagectomy and colon interposition to replace the portion of esophagus removed.

COMMON GIT SYMPTOMS AND MANAGEMENT DUMPING SYNDROME

• • •

A condition of rapid emptying of the gastric contents into the small intestine usually after a gastric surgery Symptoms occur 30 minutes after eating Refers to unpleasant set of vasomotor and GI symptoms who has gastric surgery or vagotomy.

Pathophysiology •

Foods high in CHO and electrolytes must be diluted in the jejunum before absorption takes place.

• •

The rapid influx of stomach contents will cause distention of the jejunum early symptoms The hypertonic chyme will draw fluid from the blood vessels to dilute the high concentrations of CHO and electrolytes Later, there is increased blood glucose stimulating the increased secretion of insulin

•

Then, blood glucose will fall causing reactive hypoglycemia

•

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Assessment Findings: early symptoms 1. Nausea and Vomiting 2. Abdominal fullness 3. Abdominal cramping 4. Palpitation 5. Diaphoresis

ASSESSMENT FINDINGS: LATE Symptoms 6. Drowsiness 7. Weakness and Dizziness 8. Hypoglycemia

Clinical Manifestations • • • • •

Sensation of fullness, weakness, faintness, dizziness, palpitations, diaphoresis, cramping pains, diarrhea Increase glucose followed by increase insulin (Reactive Hypoglycemia) – very unpleasant to patient. Vasomotor symptom occur 10-90mins. After meal are pallor, perspiration, palpitations, headache, feeling of warmth, dizziness, drowsiness and anorexia. Steatorrhea – common after gastric surgery Vitamin Deficiency – Vit. B12 and Iron

Nursing Interventions 1. Advise patient to eat LOW-carbohydrate HIGH-fat and HIGH-protein diet 2. Instruct to eat SMALL frequent meals, include MORE dry items. 3. Instruct to AVOID consuming FLUIDS with meals 4. Instruct to LIE DOWN after meals 5. Administer anti-spasmodic medications to delay gastric emptying • • • • • • • •

Needs to delay stomach emptying assuming fowler’s position during mealtime, after meal lie down for 20-30 mins. Antispasmodic Discourage fluid intake with meals Fluids may be consumed up to 1 hour before or 1 hour after mealtime Meals should contain more dry items than liquid items Low Carbohydrates Small frequent meals

Complications • •

Hemorrhage Shock

CONDITION OF MALABSORPTION • •

Inability of digestive system to absorb one or more of major vitamins (esp. Vit. B12), minierals(Fe & Ca) and nutrients (CHO, Fats and Protein) Most common cause – Diseases of the Small Intestine

Pathophysiology • •

Mucosa (transport) disorders  Ex. Celiac sprue, regional enteritis, radiation enteritis Infectious disease  Ex. Small bowel bacterial overgrowth, tropical sprue, Whipples disease 10

• • •

Luminal problem causing malabsorption  Ex. Bile acid deficiency, ZES, Pancreatic insufficiency Postoperative malabsorption  ex. After gastric or intestinal resection Disorders that cause malabsorption of specific nutrients  Ex. Disaccharidases deficiency leading to lactose intolerance

PERNICIOUS ANEMIA

•

Results from Deficiency of vitamin B12 due to autoimmune destruction of the parietal cells, lack of INTRINSIC FACTOR or total removal of the stomach

Assessment • • • • • • •

Severe pallor Fatigue Weight loss Smooth BEEFY-red tongue Mild jaundice Paresthesia of extremities Balance disturbance

NURSING INTERVENTION •

Lifetime injection of Vitamin B 12 weekly initially, then MONTHLY

INTESTINAL AND RECTAL DISORDERS CONSTIPATION • •

Abnormal infrequency or irregularity of defecation, abnormal hardening of the stools that makes their passage difficult and sometimes painful, a decrease in stool volume, or retention of stool in the rectum for a prolonged period. May be caused by certain medications, rectal or anal disorders, obstruction, metabolic, neurologic and neuromuscular conditions, endocrine disorders, lead poisoning and connective tissue disorders.

Pathophysiology • •

Poorly understood. Interference with mucosal transport, myoelectric activity, or processes of defecation.

Clinical Manifestations • • • • • • • •

Abdominal distention Borborygmus Pain and pressure Decreased appetite Headache, fatigue Indigestion Sensation of incomplete emptying Passage of scybala

Assessment and Diagnosis • •

Chronic constipation is usually considered idiopathic, but secondary causes should be eliminated. Diagnosis is based on results of the patient’s history, physical examination, possibly a barium enema or sigmoidoscopy, and stool testing for occult blood.

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Complications • • • •

Hypertension Fecal impaction Hemorrhoids and fissures Megacolon

Medical Management • • •

Treatment is aimed at the underlying cause of constipation and includes education, bowel habit training, increased fiber and fluid intake, and judicious use of laxatives. Enemas and rectal suppositories are generally not recommended for constipation and should be reserved for the treatment of impaction or for preparing the bowel for surgery or diagnostic procedures. Further studies are being carried out on cholinergic agents (e.g., bethanechol), cholinesterase inhibitors (e.g., neostigmine), and prokinetic agents (e.g., metoclopramide) to determine the role of these agents in treating constipation.

Nursing Management • • • • • • • •

Elicit information about the onset and duration of constipation, past and present elimination patterns, the patient’s expectation of normal bowel elimination, and lifestyle information during health history review. Past medical and surgical history, current medications, and laxative and enema use are important, as is information about the sensation of rectal fullness or pressure, abdominal pain, excessive straining at defecation and flatulence. Patient education and health promotion Restoring and maintaining a regular pattern of elimination Ensuring adequate intake of fluids and high-fiber foods Teach methods to avoid constipation Relieve anxiety about bowel elimination patterns Avoid complications

DIARRHEA • • •

• • •

Increased frequency of bowel movements (more than three per day), increased amount of stool volume (more than 200 g per day), and altered consistency (i.e., looseness) of stool. Associated with urgency, perianal discomfort, incontinence, or a combination of these factors. Caused by increased intestinal secretions, decreased mucosal absorption, or altered motility. Acute diarrhea is most often associated with infection, and is usually self-limiting. Chronic diarrhea persists for a longer period (three weeks), and may return sporadically. Diarrhea can be caused by certain medications, tube feeding formulas, metabolic and endocrine disorders, viral or bacterial infectious processes, nutritional and malabsorptive disorders and anal sphincter defects.

Pathophysiology

• •

Types of diarrhea: secretory, osmotic and mixed diarrhea.

•

Osmotic diarrhea occurs when water is pulled into the intestines by the osmotic pressure of unabsorbed particles, slowing the reabsorption of water.

•

Mixed diarrhea is caused by increased peristalsis (usually from IBD) and a combination of increased secretion and decreased absorption in the bowel.

Secretory diarrhea is usually high-volume diarrhea caused by increased production and secretion of water and electrolytes by the intestinal mucosa into the intestinal lumen.

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Clinical Manifestations • • • • • • • • •

Increased frequency and fluid content of stools Abdominal cramps and distention Intestinal rumbling Anorexia and thirst Painful spasmodic contractions of the anus and ineffectual straining (tenesmus) Watery stools are characteristic of small bowel disease. Loose, semisolid stools are associated more often with disorders of the colon. Voluminous, greasy stools suggest intestinal malabsorption. Presence of mucus and pus suggests inflammatory enteritis or colitis.

Assessment and Diagnostic Findings • • • • • •

Complete blood count Chemical profile Urinalysis Routine stool examination Stool examinations for parasitic or infectious organisms, bacterial toxins, blood, fat and electrolytes. Barium enema may assist in identifying the cause.

Complications • • •

Fluid and electrolyte imbalance (cardiac dysrhythmias) Renal failure Multiorgan failure and death

Medical Management • •

Primary management is directed at controlling symptoms, preventing complications, and eliminating or treating the underlying disease. Certain medications may reduce the severity of the diarrhea and treat the underlying disease.

Nursing Management • • • • • • • • • • •

Assess and monitor the characteristics and pattern of diarrhea. Encourage bed rest and intake of fluids and food low in bulk until the acute attack subsides. When food intake is tolerated, recommend a bland diet of semisolid and solid food. Avoid caffeine, carbonated beverages and very hot and very cold food. Restrict milk products, fat, whole-grain products, fresh fruits and vegetables for several days. Administer antidiarrheal medications such as diphenoxylate (Lomotil) and loperamide (Imodium) as prescribed. IV therapy for rapid rehydration especially for the elderly and those with preexisting GI conditions. Monitor serum electrolyte levels Report immediately clinical evidence of dysrhythmias or a change in the level of consciousness. The perianal area may be excoriated because diarrheal stool contains digestive enzymes that can irritate the skin. The patient should follow a perianal skin care routine to decrease irritation and excoriation. Use skin sealants and moisture barriers as needed.

INFLAMMATORY BOWEL DISEASE

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Normal

• • • • • • • • •

with IBD

Refers to two chronic inflammatory GI disorders: regional enteritis (i.e., Crohn’s disease or granulomatous colitis) and ulcerative colitis. The cause is still unknown. Researchers think it is triggered by environmental agents such as pesticides, food additives, tobacco, and radiation. NSAIDs have been found to exacerbate IBD. Allergies and immune disorders have also been suggested as causes. One of the most common GI problems Women > men Cause is unknown Factors associated with the syndrome o Heredity, psychological stress or condition, high fat diet, stimulating or irritating foods, alcohol consumption and smoking

Pathophysiology • • • •

Functional disorder of intestinal motility Related to neurologic regulatory system, infection or irritation Vascular or metabolic disturbance Evidence of inflammation or tissue changes in the intestinal mucosa

Clinical Manifestations • • • •

Altered bowel patterns Constipation, diarrhea or combination Pain, bloating and abdominal distention Abdominal pain sometimes preciipitated by eating and frequently relieved by defacation. CROHN’S DISEASE

ULCERATIVE COLITIS

COURSE EARLY PATHOLOGY

Prolonged, variable Transmural thickening

Exacerbations, remissions Mucosal ulceration

LATE PATHOLOGY

Deep, penetrating granulomas Mucosal minute ulcerations

LOCATION

Ileum, right colon (usually)

Rectum, left colon

BLEEDING

Usually not, but may occur

Common – severe

PERIANAL INVOLVEMENT

Common

Rare – mild

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FISTULAS

Common

Rare

RECTAL INVOLVEMENT

About 20%

Almost 100%

DIARRHEA

Less severe

Severe

RADIOGRAPHY

Regional, discontinuous lesions Narrowing of colon Thickening of bowel wall Mucosal edema Stenosis, fistulas

SIGMOIDOSCOPY

May be unremarkable unless accompanied by perianal fistulas Distinct ulcerations separated Friable mucosa with pseudopolyps or by relatively normal mucosa in ulcers in the left colon. the right colon Corticosteroids, sulfonamides Corticosteroids, sulfonamides Antibiotics Bulk hydrophilic agents Parenteral nutrition Antiobiotics Partial or complete colectomy, Proctocolectomy, with ielostomy with ileostomy or anastomosis Rectum can be preserved in only a few Rectum can be preserved in patients “cured” by colectomy some patients Small bowel obstruction Toxic megacolon, perforation, Right-sided hydronephrosis hemorrhage Nephrolithiasis Malignant neoplasms Cholelithiasis Pyelonephritis Arthritis, retinitis, iritis Nephrolithiasis Erythema nodosum Cholangiocarcinoma

COLONOSCOPY THERAPEUTIC MANAGEMENT

SYSTEMIC COMPLICATIONS

Diffuse involvement No narrowing of colon No mucosal edema Stenosis rare Shortening of colon Abnormal inflamed mucosa Abnormal inflamed mucosa

HERNIAS • • •

protrusion of an organ or part of an organ through the wall of the cavity FACTORS: caused by failure of certain normal openings to close during fetal development increased intra-abdominal pressure

Inguinal hernia -

protrusion of peritoneum through the abdominal wall in the inguinal canal • most often in males, bilateral

•

mass in scrotum

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Femoral hernia – protrusion of peritoneum through the wall femoral canal • more frequent in girls

•

mass at anterior surface of the thigh

Assessment • history of intermittent appearance of a mass in the groin Intervention • surgery – as soon as diagnosis is made; rarely close spontaneously Nursing intervention • if incarceration occurs – apply ice bag; elevate foot of bed post op: small dressing; encourage to ambulate; resume activities gradually

CONDITIONS OF THE LARGE INTESTINE DIVERTICULOSIS AND DIVERTICULITIS Diverticulosis •

Abnormal out-pouching of the intestinal mucosa occurring in any part of the LI most commonly in the sigmoid

Diverticulitis •

Inflammation of the diverticulosis

Pathophysiology

•

Increased intraluminal pressure, LOW volume in the lumen and Decreased muscle strength in the colon wall herniation of the colonic mucosa

Assessment findings for D/D • • • • • •

Left lower Quadrant pain Flatulence Bleeding per rectum nausea and vomiting Fever Palpable, tender rectal mass

Diagnostic Studies 16

• • •

If no active inflammation, COLONOSCOPY and Barium Enema CT scan is the procedure of choice! Abdominal X-ray

Nursing Interventions 1. Maintain NPO during acute phase 2. Provide bed rest 3. Administer antibiotics, analgesics like meperidine (morphine is not used) and anti-spasmodics 4. Monitor for potential complications like perforation, hemorrhage and fistula 5. Increase fluid intake 6. Avoid gas-forming foods or HIGH-roughage foods containing seeds, nuts to avoid trapping 7. introduce soft, high fiber foods ONLY after the inflammation subsides 8. Instruct to avoid activities that increase intra-abdominal pressure

BOWEL OBSTRUCTION Condition where the segment of the intestine is obstructed by: • Tumors • Paralysis • Volvolus

Signs and Symptoms • • • • •

Abdominal pain Abdominal rigidity Increased BOWEL sound in early stage and ABSENT BOWEL sound in late stage Abdominal distention Vomiting and fluid imbalance

Diagnosis •

Abdominal x-ray

Management • •

Surgery Nursing care of abdominal surgery

MORBID OBESITY • • • • •

One in three Americans is >20% of BMI Defined as more than 2x IBW Increase risk for cardiovascular disease, arthritis, asthma, bronchitis and diabetes. Suffer from low self-esteem Impaired body image and depression

Medical Management •Sibutramine HCl (Meridin) – decrease in appetite •Orlistat (Xenical) – prevent digestion of fats

Surgical Management o

Bariatric Surgery • Jejunoileal bypass – has high complications • Gastric bypass – Roux-en-Y gastric by pass is recommended for long term weight loss • Vertical banded gastroplasty by laparoscopy or open surgical technique

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Management •After weight loss – Lipoplasty or Panniculectomy

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