Major Organs of Digestion and Absorption

Digestive System 1. digestion - Digestion is the breakdown of food into small molecules, which are then absorbed into the body 2. absorption.

2 PARTS OF DIGESTIVE SYSTEM

1. The gastrointestinal (GI) tract (alimentary canal) - is a continuous tube with two openings, the mouth and the anus. - It includes the mouth, pharynx, esophagus, stomach, small intestine, and large intestine. into blood or lymphatic vessels.

2. Accessory organs include the teeth and tongue, salivary glands, liver, gallbladder, and pancreas.

A. Stomach 1. general anatomic regions a. cardia b. fundus c. body d. pyloric region - stomach is important in the process of physical digestion - rugae are undulations in stomach wall to help grind - pyloric sphincter regulates entry into the duodenum . - chyme is liquified digested material

four major secretory cells a. chief cells - pepsinogen activation of pepsinogen by low pH to form pepsin pepsin is a protease for protein digestion b. parietal cells - HCl secretion enhanced by histamine via H2 receptors Tagamet blocks H2 histamine receptors to inhibit HCl secretion - intrinsic factor binds to and allows B12 absorption in intestines c. G-cell - gastrin hormone gastrin activates gastric juice secretion & gastric smooth muscle churning gastrin activates gastroileal reflex which moves chyme from ileum to colon d. mucus cell - protective role of mucus against acids and digestive enzymes

B. Gastric Activity 1. major action in the stomace are secretion of gastric juice & contraction of smooth muscle 2. three major mechanisms of gastric regulation a. cephalic phase - initiated by parasympathetic activation (vagal innervation) - . cortical (smell, thoughts, etc.) activation of medulla - medulla activates gastric juice secretion - medulla activates gastrin secretion - medulla activates smooth muscle churning

b. gastric phase - food mass and chemicals trigger parasympathetic reflex - enhance parasympathetic activation of stomach - activate & enhance emptying of chyme into duodenum C. intestinal phase

C. Small Intestine 1. major site of chemical digestion & absorption 2. approx. 21 ft long/ 1inch diameter 3. three major segments a. duodenum ~10 inches b. jejunum ~8 ft c. ileum ~ 12 ft

Histology - mucosa has intestinal glands (cavities) for secretion of intestinal juice - mucosa also has circular folds, villi & microvilli for increased surface area - brush border has many enzymes embedded in plasma membranes * several carbohydrate-digesting enzymes * peptidases * nucleosidases * enterokinase is released by epithelial cell shedding

I. Large Intestine 1. major function to absorb water and eliminate indigestable matter 2. major structures a. cecum with vermiform appendix b. ascending, transverse, descending colon c. sigmoid colon, rectum d. haustra are pouches in wall of large intestine i. haustral churning is sequential movement of contents from one haustra to the next ii. gastrocolic reflex is rapid peristalsis in LI triggered by food in stomach

3. normal bacterial flora colonize colon a. vitamin K synthesis by E. coli bacterium 4. vermiform appendix a. lymphatic structure attached to cecum

Accessory organs

Pancreas 1. approx 1.5L/day pancreatic secretions produced 2. secretions enter duodenum via two pancreatic ducts 3. many different components in these secretions a. NaHCO3 buffers pH of chyme b. pancreatic amylase c. trypsinogen, chymotrypsinogen, carboxypeptidase - trypsinogen activated by enterokinase to become trypsin - . trypsin acts on other proteases to activate them d. lipases e. ribonucleases

Liver - is largest gland in body - overall function to filter and process nutrient-rich blood delivered to it Functions: 1.receives nutrient-rich blood from SI via the hepatic portal vein 2.many functions to liver besides aiding in digestion 3. regulates carbohydrate metabolism a. glucose secretion into blood/absorption from blood into glycogen storage b. regulated by insulin & glucagon (endocrine review) 4.regulates many aspects of lipid metabolism a. chemical digestion of fatty acids (B-oxidation) for entry into Krebs cycle b. cholesterol synthesis 5. detoxifies blood

Nutrient Absorption 1. carbohydrates a. enzymatically digested to form monosaccharides (glucose, fructose, galactose) b. absorbed in SI by active transport or facilitated diffusion c. enter blood capillary in villi, then directed to hepatic portal vein 2. proteins a. enzymatically digested to amino acids or di- and tri-peptides b. absorbed in SI by active transport or facilitated diffusion c. enter blood capillary in villi, then directed to hepatic portal vein

lipids a. enzymatically digested to short or long chain fatty acids b. suspended in SI in form of micelles with bile salts c. micelle formation aids lipid diffusion into SI epithelial lining d. inside epithelial cells, lipids bound into chylomicrons for transport e. chylomicrons transported to lacteal villi; then into lymphatics and then to venous blood

The treatment of food in the digestive system involves the following seven processes: 1. Ingestion is the process of eating. 2. Propulsion is the movement of food along the digestive tract. The major means of propulsion is peristalsis, a series of alternating contractions and relaxations of smooth muscle that lines the walls of the digestive organs and that forces food to move forward. 3. Secretion of digestive enzymes and other substances liquefies, adjusts the pH of, and chemically breaks down the food.

4. Mechanical digestion is the process of physically breaking down food into smaller pieces. This process begins with the chewing of food and continues with the muscular churning of the stomach. Additional churning occurs in the small intestine through muscular constriction of the intestinal wall. This process, called segmentation, is similar to peristalsis 5. Chemical digestion is the process of chemically breaking down food into simpler molecules. The process is carried out by enzymes in the stomach and small intestines. 6. Absorption is the movement of molecules (by passive diffusion or active transport) from the digestive tract to adjacent blood and lymphatic vessels. Absorption is the entrance of the digested food into the body. 7. Defecation is the process of eliminating undigested material through the anus.

NGT CONCEPT

TYPES OF NASOGASTRIC TUBES 1. levin and 2. Salem Sump tubes

1. levin tube - consists of a single lumen with multiple distal perforations, through which gastric contents can be aspirated or fluids / medications can be infused.

2. Salem Sump tube is a double lumen tube. - The main lumen (which is similar to the Levin tube) is used for aspiration and infusion - the secondary (smaller and blue colored) lumen serves to vent the tube to the atmosphere, preventing excessive vacuum at the distal tip and allowing continued evacuation of the stomach contents

Standard Sizes:

Children Adult -

-

Fr 5-12 Fr 13-18

NASOGASTRIC TUBE INSERTION

Indications Gaining access to the stomach and its contents. drain gastric contents, decompress the stomach, obtain a specimen of the gastric contents, or introduce a passage into the GI tract. allow you to treat gastric immobility, and bowel obstruction. allow for drainage and/or lavage in drug overdosage or poisoning. In trauma settings, NG tubes can be used to aid in the prevention of vomiting and aspiration, as well as for assessment of GI bleeding. NG tubes can also be used for enteral feeding initially.

Contraindications severe facial trauma (cribriform plate disruption), due to the possibility of inserting the tube intracranially. In this instance, an orogastric tube may be inserted

Pregnant ladies: In pregnancy (especially up to 7 months), enema should be strictly avoided as it increases the risk of abortion substantially. n extreme condition of piles and rectum ulcers. intestinal obstructions. Very weak people (after conditions of acute illnesses or otherwise)

Complications aspiration and tissue trauma.

Universal precautions: Gloves must be worn and if the risk of vomiting is high, the operator should consider face and eye protection as well as a gown. Trauma protocol calls for all team members to wear gloves, face and eye protection

NASOGASTRIC TUBE INSERTION

Is the insertion of a tube through a nose and into the stomach

Objectives: To remove secretions and gaseous substances from the GIT to prevent abdominal distention (DECOMPRESSION ). To instill nutritional supplements or feedings into the stomach for patients who are unable to swallow fluids ( GAVAGE). To apply intestinal pressure by means of an inflated balloon to prevent internal hemorrhage ( COMPRESSION ). o irrigate the stomach in cases of active bleeding or poisoning ( LAVAGE ). To obtain a specimen of gastric contents for laboratory studies ( When pyloric and intestinal obstruction is suspected ). To determine the amount of pressure and motor activity in the GI tract ( Diagnostic Studies )

ASSESSMENT: Bowel sounds Abdominal distention vomiting Assess patients mental status or ability to cooperate with the procedure

PLANNING: 1. Prepare the Equipments Salem sump or Nasogastric tube Water proof pad or towel Hypoallergenic tape Water soluble KY jelly Penlight Glass of water Straw . Connecting tube Emesis basin . Stethoscope Asepto syringe . Suction apparatus Rubber band . Gloves Normal saline solution

2. Prepare the Patient: Explain the procedure Tell the patient that he may feel some discomfort in his nose and that the procedure may cause him to gag or shed tears. Have the patient practice mouth breathing, panting and swallowing to facilitate easy insertion of the tube. Establish hand signal techniques he can use when he needs a rest during the insertion Remove dentures that do not fit well. Determine the size o the tube to be use and whether or not the tube is attached to suction.

IMPLEMENTATION:1. Remove the NGT from the package 2. Measure the Length of NGT to be inserted using either of the following methods: Measure distance by holding distal end of the tube to the tip of the nose to the earlobe Hold the distal end of the tube from the earlobe to the xiphoid process to measure the approximate length of the tube that will reach the stomach 3. Place an adhesive tape to indicate total length you have measured this will serve as marker to indicate that the approximate length of the tube has already been inserted 4. Prepare the tube .Curve end of the tube around fingers and hold for a few seconds to facilitate tube passage 5. Put on gloves

6. Lubricate the first 2 to 3 inches of the tube with KY jelly.( Never use mineral oil or petroleun jelly) lubricants reduces friction between the mucous membrane and the tube, thus prevent nasal injury to the nasal passages.(An oil based lubricant such as petroleum jelly will not dissolve and could cause respiratory complications it enters the lungs.A water soluble lubricant dissolves if the tube accidentally ewntes the lungs) 7. have the patient hold his head up straight. Then carefully insert the tube into the nostril with better airflow the passage of the tube is facilitated by following the normal contour of the body

8. Aim the tube toward the patients ear and downward, gently passing it into the oropharynx 9. When the tube reaches the patient nasopharynx, you will feel some resistance. Tell the patient to lower his head slightly. Flexed head partially occlude the airway and the tube to less likely to enter the trachea 10. Rotate the tube about 10 degrees toward the nostril this prevent the tube from entering the patient mouth 11. Check emesis basin on the bedside table in front of the patient. (prepared before the start of the procedure ) to catch for vomitous in cases the patient will vomit

12. Hand him a glass of water with straw and tell him to swallow . As the patient swallow slowly advance the tube.( Do not force to insert the tube than the patient can swallow) . swallowing closes the epiglottis that facilitates the passage of tube into the esophagus. 13. If the patient is in respiratory distress, the tube may be in the bronchus. Withdraw the tube immediately. to prevent complication 14. Stop advancing the tube when you reach the adhesive tape or other marking used.

15. Confirm placement of the tube by: aspirating stomach contents with an asepto syringe, check the pH aspirated gastric contents indicates that the tube is in the stomach. 16. Inject 5-10 cc of air into the tube as you auscultate for a whooshing sound over the epigastric region. air can be detected by a whooshing sound entering the stomach Submerging the distal end of the tube in a water if there is bubbling it means that the tube is in the bronchus If the measures do not confirm proper placement request for a chest x-ray

17. Secure end of the tube with tapes or with a clip to prevent air from unnecessary entering the tube causing abdominal distention 18. Secure the tube by taping it to the bridge of the clients nose if the client has oily skin, wipe the nose first with alcohol. Cut the tape, and split it in lengthwise 19. Unglove hands 20. Loop the tube, secure it with a rubber band and attach to patients gown to reduce discomfort from the weight of the tube

21. Pin the end of the tube above the stomach to prevent reflux of gastric content 22. Attach NGT to connecting tubing and solution apparatus as ordered. If there is no order, keep tip of the tube closed. 23. Chart procedure and reactions of the patient. 24. Do after care Inspect the nost ril for discharge and irritation Clean the nostril and tube with moistened cotton tipped applicators Apply water-soluble lubricant to the nostril if it appears dry or encrusted

Nursing Considerations: 1. Partially pre-freezing the tube can ease its passage. 2. Infants can suck on a pacifier during the procedure. 3. Dont rely on a cuffed endotracheal tube to prevent passage into the trachea be sure and confirm placement using the above methods.

BOWEL DIVERSION OSTOMIES

Colostomy Temporary or permament opening of the colon through the adominal wall

Indications :

cancer of the rectum or rectosigmoid area, perforating diverticulum, trauma.

ILEOSTOMY Opening from the ileum or small intestine through the abdominal wall. Bypasses the entire large intestine.

Indications

: ulcerative colitis, Crohns disease, trauma, cancer, birth defect.

STOMA - Part of the colon that is brought above abdominal wall in an ostomy and becomes the outlet for discharge of intestinal contents

1. LOOP STOMA Temporary large stoma where loop of bowel is brought to abdominal surface and opening created in anterior wall of bowel to provide fecal diversion

2. END STOMA - One stoma formed from the proximal end of the bowel with the portion of the GI tract either removed (permanent) or sewn closed (Hartmanns pouch) and left in the abdominal cavity.

3. DOUBLE BARREL STOMA - Bowel is surgically severed and two ends are brought out onto the abdomen as two separate stomas. The proximal end is the functional stoma. The distal end is nonfunctioning, called a mucus fistula. Intended as a temporary diversion in cases where resection is required due to perforation or necrosis.

Good stoma

Bad stoma

What else should you expect to see when you examine the stoma? 1. There should be mild to moderate edema in the first 5-7 days post-op. Severe edema may indicate obstruction of the stoma, allergic reaction to food or gastroenteritis. 2. Blood oozing from the stomal mucosa when touched is normal because it is so vascular.

NURSING CONSIDERATIONS: 1. Tension at the stoma site where it is sutured to the skin can create poor healing or necrosis of the stomal skin edge and retraction of the stoma into the abdomen. This is called Mucocutaneous separation 2. It is a gradual process because the patient experiences grief over the loss of a body part and an alteration in body image. 3. Adjustment period is individualized. 4. Patients are concerned about body image, sexual activity, family responsibilities and changes in lifestyle

TYPES OF OSTOMY POUCH APPLIANCE

1. One piece disposable pouch - odor-proof plastic pouch with an attached adehsive or karaya seal. Open-end pouch - drainaable disposable pouch with a closure clamp attached to skin barrier, may be used permanently ro temporarily Closed end pouch - may come in a kit with adhesive seal, belt tabs, skin barrier or

2. Two piece disposable pouch - Drainable pouch with separte skin barrier that permits frequent changes and minimizes skin breakdown. 3. Reusable pouch - Typically made of sturdy, hypoallergenic plastic that comes with separate cutom-made facelate and O - ring.

STOMA CARE 1. the first step is looking at the stoma, progressing to assisting with emptying and cleaning, and then to changing the pouch. 2. If the patient cannot progress to the point of willingness to learn, a caregiver must be taught pouch change procedure and care until the patient is ready to learn

3. Pouch change is best performed before eating because the stoma is less active. 4. Ideally, the pouch should be changed every 5 to 7 days, but if it leaks it must be changed immediately.

5 . Pouches are made of odorproof plastic, but if the bag is not cleaned adequately when emptied or if a leak has developed, there will be an odor. 6 . There are products on the market to eliminate odordrops that can be put in the bag at changing or cleaning, odor neutralizing sprays when the pouch is changed, or bags with built in charcoal filters.

7. Remind your patient how important it is to have them examine the peristomal skin for any sign of breakdown. It is so much easier to prevent this rather than heal the skin! 8. Patients may bathe or shower with or without the pouch. Patients may swim with the pouch in place as well.

9. Routinely wash with warm water. Soap is likely to leave a residue that can cause dermatitis and decrease the adhesiveness of the pouch. If soap is used be sure to avoid ones with oils and rinse thoroughly. 10. Commercial cleansing wipes are convenient when away from home as long as they dont contain lanolin or emollients. Tucks works well.

Points to Consider:1. The opening should be about 1/8 inch larger than the stoma. 2. Teach your patient to empty the pouch when it is no more than 1/3 full and to cleanse the pouch from the bottom with a squeeze bottle filled with water (one piece unit). The two piece unit can be snapped off, washed and snapped back on. 3. Change the entire unit (one or two piece) every 47 days depending on stability of seal. 4. Remind your patients to not lift anything over 10 pounds for the first 6 to 8 weeks after surgery, otherwise they may resume normal activities

COLOSTOMY IRRIGATION:

Basic Concept: Irrigating a colostomy is a procedure similar to that of enema which is done for the main purpose of distending the bowel sufficiently to stimulate peristalsis and therefore evacuation of bowel.Objectives: 1.To empty colon the colon of its content of feces, gas and mucus 2.To cleanse the lower intestinal tract 3.To establish regular pattern of evacuation so that the normal life activities may be pursued.

enema is the procedure of introducing liquids into the rectum and colon via the anus.

Types of Enema Enema varies according to the temperature of the water. 1. Cold Enema: 50of-65of (or 10oC-18oC). It is helpful in decreasing fever and it is also beneficial in inflammatory conditions of the colon especially in cases of dysentery, diarrhea, ulcerative colitis and hemorrhoids. Caution: a. Don't turn on the Enema nozzle fully. Take 1015m. time undergoing Enema practice. b. In the case of ulcers and hemorrhoids, take 10gm of dried Neem leaves (powder) boiled in 1 liter of water, & then allow to cool. Strain this water and then use. To buy this invaluable herb for enema

2. Warm Enema: 97oF-100oF(or 36oC-38oC) is recommended for general fitness and well being once a week. It helps to cleanse the rectum of the accumulated tassel matter. This is not only the safest system for cleaning the bowel but also improves the peristaltic movement of the bowels and thereby relieves constipation.

3. Hot Enema: 104oF-115oF (or 40oC-45oC) is beneficial on sudden occasions such as stoppage / obstruction of tassel matter and intestinal gas in which you may also feeling be mentally uncomfortable. Hot Water Enema is beneficial in relieving irritation and pain due to inflammation or rectum, painful hemorrhoid. It also helps leucorrhoea in women. It is also beneficial in general abdominal pain, abdominal pain due intestinal gas and pain of kidney, liver and spleen. Caution: a. The quantity of water used should be - liter and the enema duration should be for 10mins. b. In the case of ulcers and hemorrhoids, boil 10 gm of dried neem leaves (powder) in 1 litre of water, & then allow to cool. Strain this water and then use.

4. Graduated Enema: In graduated Enema the amount and temperature of water is slowly decreased up to the 15th day. It is started with 2 liter of water and decreased by 125 ml per day up to 125 ml. on 15th day. In the case of temperature , it is slowly decreased from 100o F to 70o F (i.e. 2o per day). It is highly beneficial in cases where intestines are over dilated and it improves the intestinal function.

Types of enema: 1. Cleansing enema Prevent the escape of feces during surgery. Prepare the intestine for certain diagnostic tests such as x-ray or visualization tests (e.g. colonoscopy). Constipation or impaction. Cleansing enema: (high): Given to cleanse as much of the colon as possible. Left lateral position to the dorsal recumbent position and then to the right lateral position during the administration so that the solution can follow the large intestine. The solution container is usually held 12 to 18 inches above the rectum because the fluid is instilled farther to clean the entire bowel. Cleansing enema (low): Cleanse the rectum and sigmoid colon. Maintains a left lateral position during administration.

2. Carminative enema: Distends the rectum and colon with gas released from the enema solution. For an adult, 60 to 80 mL is instilled. 3. Retention enema: Introduces oil or medication into the rectum (types): 4. Return-flow enema: Alternating flow of 100 to 200 mL of fluid into and out of the rectum and sigmoid colon stimulates peristalsis. Repeated five or six times until the flatus is expelled and abdominal distention is relieved.

Commonly used enema solutions Hypertonic: 90 to 120 mL of solution (e.g. sodium phosphate). Hypotonic: 500 to 1,000 mL of tap water. Distends colon, stimulate peristalsis, and softens feces. Effective in 15 to 20 minutes. Fluid and electrolyte imbalance; water intoxication. Isotonic: 500 to 1,000 mL of NS. Distends colon; stimulates peristalsis, and softens feces. Effective in 15 to 20 minute. Adverse effects: Possible sodium retention. Soapsuds: 3-5 mL soap to 1,000 mL water. Irritates mucosa, distends colon. Effective in 10 to 15 minutes. Adverse effects: Irritates and may damage mucosa.

ENEMA Is The installation of solution into the rectum and sigmoid colon Objectives : Bowel preparation or diagnostic tests or surgery to empty the bowel of fecal content. delivery of medication into the colon To soften the stool To relieve gas To promote defecation and evacuate feces from the colon

ASSESSMENT: Verify Doctors order- the kind and temperature of enema, amount and time to give, purpose of enema. Assess client for any rectal pathology. Assess vital signs to establish baseline data. determine clients condition and age Determine when the client last had a bowel movement and the amount, color and consistency of the feces Assess for abdominal distention. Assess the clients ability to use the toilet. Bed pan or commode chair. Assess the diet of the client. Know instructions of pre-packaged enemas.

PLANNING: gather equipments needed enema can/container tubing t the connect the container to the rectal tube clamp rectal tube of correct size lubricant bath thermometer

bath thermometer enema solution bath blanket water proof pad/ cotton draw sheet tissue wipes bed pan or commode clean gloves kidney basin additional blanket when needed Recall of related principles Explain the procedure to the patient Provide privacy

IMPLEMENTATION 1. Place rubber sheet and cotton draw sheet or water proof pas under the buttocks of the patient to prevent soiling of the bottom sheet 2. Drape patient with bath blanket 3. Position the patient in Sims left lateral position to expose the anus 4. Open clamp. Run some solution to connecting tubing and rectal tube to expel air in tubing, close clamp. Air installed into the rectum although not harmful, causes unnecessary distention

5. Wear gloves 6. Lubricate 5 cm ( 2 inches) of the rectal tube lubrication facilitates insertion , thus minimize trauma of sphincter 7. Lift upper buttocks to ensue good visualization of the anus 8. Instruct the patient to breath through the mouth and to relax the anal sphincter allows patient relaxation and readiness 9. Insert the lubricated tip smoothly and slowly into the rectum directing it toward the umbilicus the angle follows the normal contour of the rectum 10. Insert the tube 7-10 cm ( 3-4 inches) for adults, 5-7 cm ( 2-3 inches for children ( 1 1.5 inches ) for infants. Insertion to this Pont places the tip of the tube beyond the anal sphincter into the rectum.

11. If resistance is encountered at the internal sphincter, ask the client to take a deep breath then run a small amount of solution through the tube to relax and internal anal sphincter 12. If resistant persists, withdraw the tube, and report the resistance to the Nurse in change and the physician 13. Slowly administer the enema solution 14. raise the solution container ( 12-18 inches above ) and open the clamp to the allow the fluid flow. The higher the solution container is held above the rectum, the faster the flow and the greater the force in the rectum.

15. If the client complains of fullness or pain, sue the clamp to stop the flow for 30 seconds. Restart at a slower rate. Rapid infusion can cause colon distention and cramping. Administering the enema slowly and stopping the flow momentarily decrease the like hood of intestinal spasm and premature ejection of solution. 16. When the correct amount of fluid has been instilled or when the client has the urge to defecate. Close the clamp and remove the rectal tube from the anus.

17. Place the rectal tube in a paper as it is withdrawn. 18. Apply firm pressure over the anus with tissue wipes or press the buttocks together to assist retention of enema. Ask the client to remain lying down. Encourage the client to hold enema for as longs as possible it is easier to retain the enema when in lying down. 19. Remove gloves Assist the client to defecate bedpan commode toilet bowl if specimen is required use bedpan

20. .Make patient comfortable Do after care 21. Wash hands 22. Chart amount, color, consistency of feces presence of unusual constituents relief of discomforts ( flatus, abdominal distention)

MYTHS about Enema

Myth #1: It is Difficult Reality: Quite contrarily, it is one of the easiest methods of thorough colon cleansing. Following the instructions as provided in the enema instruction booklet will make you aware how wonderfully easy the procedure is.

Myth #2: It is Habit Forming Reality: In nature cure, patients who were given enema for months did not take even a day to leave it or live without it. Myth #3: It Weakens the Intestine Reality: It never weakens the intestine and rectum; instead taking enema rationally activates and strengthens them

NURSING Considerations: 1. In enema, water plays an important role and we should always use safe water for colon cleansing. Unfiltered, chlorinated water harms the colon lining and kills good microbes. 2. Chemicals should be avoided in the use of enema because they irritate the colon tissues. When we use chemicals, some of it stays in the blood stream and loads up the work of the liver. Water should be filtered, preferably with a carbon based shower filter or a reverse osmosis system for best results.

3. When undergoing an enema, the process should be slow and one should not rush to end up the process soon. Mostly people can take 1-3 quarts of water into the colon but it should be done slowly - about one cup per minute. 4. The temperature of water also plays an important role; so don't take in the water too cold because it can bring in lot of needless pain; on the other hand, 5. if the water is too hot, it might harm the sensitive tissues of the colon.

The genuine knowledge originates in direct experience

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