Esophageal and Gastric Disorders

Esophageal and Gastric Disorders

• Esophageal and Gastric Disorders include Esophagitis, GERD, Peptic Ulcer Disease, Esophageal Cancer, and GI Bleeds.

A & P Review: GI Tract

• The Gastrointestinal (GI) Tract includes: -Mouth, teeth, tongue, salivary glands -Pharynx -Esophagus -Stomach -Small Intestines: duodenum, jejunum, and ileum that are arranged in folds to slow chyme passage for absorption -Large Intestines: cecum, colon (ascending, transverse, descending, sigmoid), and rectum -Ascending colon is responsible for fluids and electrolytes absorption

Nutrition Overview

• Most GI conditions require dietary restrictions or recommendations in food selection.
• Tube feeding: Supplemental or total nutrition via NG tube, PEG/PEG tube -Uses: poor swallowing or nutritional deficiencies not related to absorption/diarrhea -Pros: relatively inexpensive, managed by patients/families, and can be continuous or intermittent -Cons: risk for aspiration/diarrhea and challenges with glucose control.
• TPN: Supplemental (PPN) or total nutrition via IV access -Uses: patients with poor absorption and/or diarrhea or cannot tolerate food in the GI system -Pros: bypasses the GI system and can be fully customized -Cons: Requires central IV access, with risks of infection, glucose control challenges, and cost.

Esophagitis and GERD

• GERD involves the upward flow of gastric contents through the lower esophageal sphincter (LES). -This flow causes chronic irritation to the esophageal lining. -Reflux esophagitis involves severe, acute symptoms of reflux.
• Causes/triggers of GERD include: -Obesity -Hiatal hernias -Smoking and EtOH -Supine position -Triggering foods, caffeine, chocolate, citrus fruits/tomatoes -Large meals/high-fat meals

GERD Clinical Manifestations

• GERD may be asymptomatic.
• Other manifestations include Dyspepsia, regurgitation, atypical chest pain, epigastric pain, belching, flatulence, bloating, coughing, hoarseness, and a feeling of something in the throat.
• Severe cases cause dysphagia and odynophagia.
• Complications include Barret's esophagus, esophageal strictures, aspiration pneumonia, asthma, cardiac issues, and dental problems.

GERD Diagnosis and Management

• Diagnosis includes a history including ROS and dietary information, diagnostic exams like barium swallow, upper endoscopy (EGD), and pH monitoring.
• The non-pharm management of GERD includes: -Dietary modifications (small meals, low fat, omit caffeine) -Weight loss -Sleeping with head elevated -Smoking and EtOH cessation
• Pharmacologic management includes chewable antacids for temporary relief (calcium carbonate, aluminum hydroxide/mag hydroxide) ,histamine receptor antagonists (famotidine, cimetidine, ranitidine), and proton pump inhibitors (PPIs): omeprazole, pantoprazole.

Esophageal Cancer

• Risk factors: GERD, Barrett's esophagus, smoking, ETOH, chronic exposure to hot liquids
• Two Types: Squamous cell and adenocarcinoma
• Manifestations: May appear late in the course of the disease
• Symptoms include include Dysphagia, fullness in throat or substernal area, regurgitation, hiccups, halitosis, and weight loss.
• Diagnosis: EGD (with Bx), CT, US, laporoscopy, genetic and molecular markers

Esophageal Cancer – Management

• Medical management: Surgery, XRT, chemo, and symptom management.
• Nursing goals/interventions: Safety of airway post-op, maintain, and/or manage trach. -NGT care: check/maintain placement and patency, oral care, and monitor bloody➜yellowish-green output. -Watch for complications/leaking from anastomosis: tachycardia, fever, signs of shock. -Maintain nutrition: high calorie, high protein, and liquid/soft enteral feedings or TPN diets -Prevent aspiration: Manage oral secretions, HOB > 30 degrees. -Promote comfort physically and emotionally.

Peptic Ulcer Disease (PUD)

• PUD involves damage to the mucosal lining of the stomach or duodenum.
• Multiple types include: -Gastric: delayed gastric emptying with reflux of bile, breaks in mucosa, decreasing blood flow and increasing irritation. -Duodenal: High gastric acid secretion (low pH), rapid emptying of food from the stomach increasing acid in the duodenum -Stress: Curling's, Cushing's, or ischemic ulcers -> rare can lead to GI bleed
• The most common causes are H. pylori infection and NSAID.
• Risk factors and other contributing factors include age > 50 years old, corticosteroids, chemotherapy, local radiation, caffeine, tobacco, and ETOH.

PUD Manifestations

• Dyspepsia: sharp, burning, gnawing, pressure/fullness
• PUD heals often and returns, with its pain exacerbated by specific foods.
• The signs and symptoms of hypovolemia or bleeding are important to check.
• Gastric Ulcers: patient malnutrition, normal acid secretion, experiences pain 30-60 min post meal or at night, rarely worsened with eating, and if bleeding occurs, the patient has hematemesis.
• Duodenal Ulcers: patient is well nourished, has over secretion of acid, experiences pain occurring 90 min-3 hrs post meals or at night, and wakes up in the middle of the night, and is relieved by eating, and if bleeding occurs, the patient has melena.

PUD Diagnosis & Collaborative Management

• Requires thorough history and ROS.
• Diagnosis includes EGD and lab testing for H. pylori (breath, stool, blood), CBC trends, fecal occult blood, and x-ray if perforation is suspected.
• Pharmacologic management: PPIs are primary treatment (oral and IV) and chronic management. -H. pylori: PPI + 2 antibiotics: metronidazole and levofloxacin -H2 blockers, mucosal barrier fortifiers (sucralfate), prostaglandin supplements (misoprostal) -Avoid causative agents (NSAIDs)

PUD Nursing Priorities and Management

• Manage pain and prevent/early detection of GI bleeding/peritonitis (see inflammatory intestinal presentation).
• Manage and teach about medication management.
• Encourage ETOH/smoking cessation.
• Controversial Nutritional Teaching; -NPO if GI bleeding -Teach to reduce/eliminate foods that cause pain. -No evidence that dietary restrictions help. -Bland and non-spicy foods reduce pain. -Small and frequent meals help.

Gastrointestinal Bleeding (GIB)

• Bleeding anywhere along the GI tract.
• Upper GI bleeds causes include PUD, esophageal varices, erosive esophagitis, and Mallory - Weiss tear.
• Lower GI bleeds (20%) causes include Diverticular Bleeding, Inflammatory Bowel Disease, Tumors or Polyps, Ischemic Bowel Disease, Arteriovenous Malformations, and Hemorrhoids.

Clinical Presentation of Upper GI Bleed

• Presentation varies based on cause of bleed.
• Symptoms include nausea/vomiting with hematemesis (coffee ground emesis) and/or Melena / hematochezia.
• Additional observations may reveal hemodynamic changes, anemia, and pain.

GIB: Diagnosis & Collaborative Management

• Diagnosis based on clinical presentation, serologic testing for H. Pylori and CBC, upper endoscopy, nuclear med scans and CT scan.
• Collaborative management: treat underlying cause (PUD), PPI for UGIB, maintain hemodynamic stability, fluids, blood products, surgical management, cauterization
• Goal is prevention.

Nursing Assessment Priorities and Diagnoses for GI Bleeds

• Assess hemodynamic monitoring (B/P, and HR) and perform laboratory monitoring for Hemoglobin, Hematocrit, PT, PTT, and platelet count
• Evaluate output and signs of worsening bleeding.
• Possible Diagnoses: -Fluid volume deficit -Imbalanced nutrition -Fear or anxiety -Knowledge deficit or risk for ineffective coping -Fatigue or activity intolerance -Pain

Nursing Interventions for GI Bleeds

• Administer supplemental oxygen, IV fluids and blood product administration.
• Vasopressin, somatostatin, and/or octreotide may be administered.
• Preparations for endoscopy, cauterization, or surgical intervention may be necessary.
• Address fear and anxiety.
• Use Interventions related to fatigue and provide education.

Non-Inflammatory Intestinal Disorders

• Non-Inflammatory Intestinal Disorders include Bowel Obstruction and Colorectal Cancer.

Types of Intestinal Obstructions

• Mechanical Obstruction: Obstruction within the lumen of the bowel or pressure from outside the lumen: intussception (A), volvus (B), tumors/neoplasms, strictures, adhesions, hernias (C).
• Functional Obstruction: Intestinal musculature unable to propel the bowel contents. This may be short term or due to chronic disease. -Short term causes: bowel manipulation during surgery, medications -Chronic disease causes: diabetes mellitus, Parkinson's disease
• Small Bowel Obstructions (SBO) are the most common, but obstructions can happen in the large bowel.

Manifestations of SBO

• Symptoms progress rapidly
• Crampy, colicky abdominal pain
• Passing blood and mucous but no stool
• Vomiting - Peristalsis becomes very strong and can reverse
• Emisis of stool
• Dehydration: Thirst, drowsiness, malaise/aching, parched tongue & mucous membranes.
• Abdominal distention – the lower the obstruction, the more the distention
• Uncorrected obstruction leads to hypovolemic or septic shock, peritonitis, and death.

Manifestations of Large Bowel Obstructions

• Symptoms progress slowly. -Constipation may be the only symptom for months Altered stool shape can be a pencil thin. -Occult or overt blood loss can cause anemia. The patient may also have weakness, weight loss and anorexia.
• Later symptoms include abdominal distention, crampy abdominal pain, and fecal vomiting.
• If uncorrected, shock peritonitis can cause death.

Intestinal Obstructions - Nursing Priorities

• Impaired comfort/pain, psychosocial dx, constipation, diarrhea, risk for infection, health maintenance, and nutritional issues are some potential diagnosis to note
• Non-surgical: NGT management, NPO, monitor for abdominal sounds/electrolytes/BMs, prepare for surgery, and perform pain management
• Surgical management: NGT management, electrolyte corrections, pain management, oxygenation

Colorectal Cancer

• The third most common cause of cancer deaths in the US, screening procedures are important.
• Symptoms may include changes in bowel habits; blood in stool-occult, tarry, bleeding; tenesmus, symptoms of obstruction, pain either-abdominal or rectal, and/or a feeling of incomplete evacuation.
• Key Risk Factors include: -Increasing age -Family history of CRC or polyps -Personal history of CRC or adenomatous polyps -High alcohol intake -Cigarette smoking and obesity -History of gastrectomy/inflammatory bowel disease and/or a high fat/high protein /high beef intake/low-fiber diet -Reproductive cancers (endometrial or ovarian) or breast cancer (in women).
• Treatment depends upon the stage and location of the disease.

The Patient with an Intestinal Diversion

• Preoperative care consideration for Placement/Positioning of stoma and IV antibiotics
• Postoperative care consideration: Frequent assessment of stoma and effluent, VS, dressings, hydration, electrolyte balance
• It's important to provide emotional support
• Also, it's important to take care of skin and stoma, making sure that the device has a proper fitting and ensure protection of skin.
• Finally consider diet and fluid intake depending on the location of the ostomy.

Considerations for Placement of Stomas

• Ideal placement should be selected pre-op by wound/ostomy RN.
• Important factors to consider are Skin folds, the locations of belts, waistlines of garments, and patient dexterity.
• Focus on an ability of patient to see/reach ostomy
• Assess all considerations with patient in various positions

Inflammatory Intestinal Problems

• Inflammatory Intestinal Problems includes Gastroenteritis, Appendicitis, Peritonitis, Diverticular Disease, Ulcerative Colitis, and Crohn's Disease.

Gastroenteritis

• Associated with nausea, vomiting, and/or diarrhea due to inflammation. Norovirus is most common.
• Highly contagious and occurs via fecal oral transmission for it. -Hand washing and surface cleaning is ESSENTIAL
• Viral shedding before and after symptoms, and it is self limiting with fluid maintenance priority
• Nursing diagnoses and priorities can include: Diarrhea, nausea, fluid volume deficit, risk for electrolyte imbalance and infection transmission as well as risks for falls (elderly). -The priorities are support; with management of fluids, electrolytes support, and patient education

Appendicitis

• Involves the Occlusion of the appendix leading to Inflammation/infection
• Clinical presentation is a sharp RLQ pain, vague epigastric/peri-umbilicus pain, fever, anorexia, n/v, pain at McBurney's point, and rebound tenderness.
• Can be diagnosed using assessment and imaging and blood tests, H&P, leukocytosis, imaging (Xray, CT, US). UA and pregnancy test also must be done
• Non-surgical vs. emergency surgery are the management options
• Complications: rupture leading to peritonitis/sepsis

Peritonitis

• Peritonitis is caused by inflammation of the peritoneum, the thin tissue that lines the inner wall of the abdomen and covers most of the abdominal organs
• This causes bacterial or other material leads to infection with edema.
• Causes include Perforation of the intestines from surgery or trauma, ruptured appendix, ulcers, and all various traumas
• Patients may experience fever, hypotension, & tachycardia

Presentation of Peritonitis

• Presents with diffuse abdominal pain ➜ severe with fever, hypotension & tachycardia, and/or decreased bowel sounds
• Physical signs that may be present are rigid, board-like abdomen with rebound tenderness
• To diagnose: Abdominal Xray can show free air and distended bowel loops and Abdominal US/CT/MRI shows abscesses and fluid
• Can be life Threatening!

Nursing and Collaborative Priorities

• Act emergently with a history to address Hemodynamic stability issues, provide IV fluids, antipyretics, and antibiotics.
• Manage pain and plan a non- surgical pathway or surgery.

Diverticular Disease

• Diverticulum is a sac-like herniations of the lining of the bowel extending through a defect in the muscle layer anywhere in the intestine, but are most common in the sigmoid colon
• Diverticulosis is the term for for multiple diverticula without inflammation
• Diverticulitis refers to infection and inflammation of diverticula which can be acute or chronic
• Diverticular disease increases with age and is associated with low-fiber diet and chronic constipation.

Diverticular Disease

• Diverticulosis is often asymptomatic and found on routine colonoscopies
• Diverticulitis is indicated through: Cramps, narrow stools, constipation with Pain, n/v, chills, fever, and leukocytosis
• Complications lead to to perforated bowel, abscesses, and GI bleed
• Dx through colonoscopy, CT, abdominal Xray, CBC must be given.

Management of Diverticulosis vs Diverticulitis

• Diverticulosis: Treat with analgesics, antispasmodics, bulk forming laxatives and a high-fiber, low-fat diet
• Diverticulitis: Treat with: IVF, PO or IV abx, opioids, antispasmodics, fiber supplements, and probiotics as diet. -If needed, NPO w/ NGT suction ➜ low fiber ➜ high-fiber and low-fat once resolved. Surgery is an option for an emergency situations or to prevent GI bleed.

Inflammatory Bowel Disease (IBD)

• Inflammatory Bowel Disease may cause exacerbations and complications to an individual and is mostly managed at home, but when serious, requires admission

IBD: Ulcerative Colitis (US)

• Chronic, inflammation within the colon because of increased blood flow and edema resulting in periodic exacerbations of diarrhea (often with blood and mucus)
• Caused by genetic, immunologic, and/or environmental factors
• Manifestations cause diarrhea, associated changes s/t diarrhea, abdominal pain, tenesmus, tachycardia, fever, anemia, leukocytosis, elevated CRP and/or ESR, colonic distention, and anxiety/depression & social isolation.

IBD: Crohn's Disease

• Chronic, inflammation in patchy areas throughout the small intestine (most common) and/or any where in the Gl tract that has thickened lining in a "cobblestone" appearance. -Ulcerations and strictures can results in unpredictable patterns of exacerbations of diarrhea.
• This can be caused by genetic, immunologic factors
• Manifestations include diarrhea, multiple loose stools per day, thickening and strictures, fistula development, associated changes s/t diarrhea, abdominal pain, fever, weight loss & poor nutrition, anemia, steatorrhea, and/or anxiety/depression and social isolation.

Ulcerative Colitis vs Crohn's Disease

• Ulcerative Colitis: Begins in the rectum and moves “up” the Gl tract with heavy, liquid/bloody stools per day -Hemorrhage and nutritional deficiencies are most common complications and rarely need surgery
• Crohn's Disease: Most often in the small intestine, patchy involvement along the whole Gl tract, with soft, loose stools which become less frequent with blood. -Fistulas and nutritional deficiencies or malabsorption are most common complications and often need surgery due to it's high severity
• Watch for with both complications: Toxic megacolon, obstructions, colorectal cancer, and can trigger peritonitis
• Both can be managed at home for the most part
• Treat the condition by managing fluid, electrolyte, and nutrition w NPO PRN and increasing fluid and caloric intake
• Biologic and immono medications can treat both conditions (-Imabs, -Umabs) as well as Antidiarrheal medications and aminosalicylates (5-ASA)
• Give Steroids to treat short exacerbations
• Help manage depression, body image, and isolation and anxiety

Hepatic Conditions

• Hepatic Conditions include Cirrhosis, Hepatitis, and Liver Cancer. Metabolism of fats, carbohydrates, and proteins occur here
• The Liver breaks down carbohydrates into glycogen, storing it until needed for glycogenolysis and gluconeogenesis
• Ammonia, Protein breakdown byproduct, toxic that is excreted later

A & P Review: Liver

• Metabolism of fat, carbohydrates, and proteins occurs here.
• The liver breaks down carbohydrates into glycogen and stores it until needed. When the body needs it; glycogenolysis and gluconeogenesis occur to produce glucose
• Ammonia, a protein breakdown byproduct, is toxic but is excreted afterward
• The liver is a blood reservoir, holding approximately 1 liter of excess volume/blood when fluid volumes are high, and can compress its to excrete volume during volume deficit.
• The Liver also produces blood clotting factors.

Assessing the Hepatic System

• Health history (toxins, drugs, ETOH)
• Physical exam (skin, abdominal, liver palpation) -Imaging (CT, MRI, US)
• Biopsy
• Labs Direct and indirect bilirubin; Serum protein and albumin, Prothrombin time, Alk phos (obstruction), AST and ALT (liver cell damage), and Serum ammonia

Causes of Liver Failure or Dysfunction:

Drug Induced, Viral, Cirrhosis, Liver Cancer primary to and metastasis

Drug Induced Liver Dysfunction/Failure:

Liver damage -acetaminophen, leading cause of acute -Liver damage -amiodarone, phenytoin, statues + Herbal Treatments and TB meds

Drug Induced Hepatic Dysfunction:

Clinical Nausea or Vomiting (better after 48 hours) w/ Jaundice Elevated ALT and AST enzymes Charcoal needs to go in via NGT to decontaminate it while acetaminophen is still in their body N-acetylcysteine (ASAP needed)

Viral Infections Leading to Hepatic Dysfunction:

Hepatitis, leading cause of liver failure worldwide, may be caused by blood and fluids Hep A- Through fecal-oral route Hepatitis B transmitted with contaminated blood or body fluids Epstein-Barr (EBV), Herpes Simplex, Yellow Fever, Cytomegalovirus (CMV)

Chronic Liver Dysfunction/Failure

• Cirrhosis Normal liver tissudisrupted or replaced with fibrosis that disrupts structure and function
• Alcoholic most common type, causes Post/necrotic necrosis, broad bands of scar tissue that causes late stage hepatitis

Manifestations of Hepatic Dysfunction: Jaundice

-yellowing of skin, eyes mucous due to increased Bilirubin

• This may be due to damaged liver cells are cells are unable to clear normal amounts of bilirubin to other viruses toxin
• Obstruction: Bile can't flow normally intestine so Becomes in the liver liver
• Hemolytic typically not associated with liver dysfunction

Manifestations of Hepatic Dysfunction: Portal Hypertension

• Obstructed portal blood flow with resultant increase in pressure within portal circulation: Ascites and or Esophageal varices. Hepatic encephalopathy may also be observed

Manifestations of Hepatic Dysfunction: Ascites

• Portal HTN capillary pressure obstruction of venous flow will cause:
• Increase Ab girth, rapid weigincreasinght gain, Umbilical hernia and short breath or discomfort 🌊fluid electrolyte imbalances
• Daily weights abdominal girth I/O and fluid weight or sodium.

Care of Patient Undergoing Paracentesis

• Can be done at bedside or in interventional radiology, perform Patient to monitor them for up right support before medicating a prodecedure
• Monitor 💧for Bleeding respiratory distess

Manifestations of Hepatic Dysfunction: Esophageal Varices

"Hemorrhoids" of the esophagus with a Caused by portal hypertension Aggravated by Trauma or irritated through chemical exercise, vomiting, blood and fluids Associated with abnormal clotting/ severe

Esophageal Varices Rupture/Hemorrhage Causes:

To treat this problem: Provide AIRWAY Compromise → Intubation in the patients, Blakemore Tube or Vasoconstrictive meds and blood products for surgery Surgery that connects the shunt procedure

Manifestations of Hepatic Dysfunction: Hepatic Encephalopathy

Manifested by Elevated ammonia levels and confusion and anxiety

• The condition can be marked through Incontinence Tremors or brain edema

Clinical Manifestations: Encephalopathy

Stages I. Normal LOC with periods of lethargy and euphoria and normal sleep II. Increase drowsiness and disorientation with inappropriate behavior and mood swings III. Stuporous states where the person hard to change state IV. Comatose and difficult in change in states

Hepatic Encephalopathy: Goals And Tx

Goal to reduce to serum ammonia provide: low protein safety. + Neuro, + Lactolouse Neomycin

Manifestations of Hepatic Dysfunction: Coagulopathy

Liver loses ability to produce due clotting factors to infection which the bleeding precautions for

Hepatic Dysfunction: General Nursing Considerations

Consider both: the specific treatment considerations for type and manifestation of Hepatic dysfunction and other different types such as Always Labs, Nero and 💉 bleeding

Problems in the Biliary System

Cholecystitis and Pancreatitis may occur

A & P Review: Pancreas

Sits below the liver that aproximatt 1-1.5L for day enzyme secretions insulin secretion is lipase

Pancreatitis

Inflammation of the acute which alcohol is also causes gallstone medications etc

Pancreatitis

The etiology is factor is the obstruction

The Pathophysiology of Autodigestion in Pancreatitis

Due to necrosis of the injury to cells

Clinical Presentation

An act pain 24 to 48 h with that radiate pain and may be that the acute inflammation level and guarding

Hemorrhagic Pancreatitis

Cullen's Sign, Grey Turner's Sign, and signs of inflammation

Complications: Acute Pancreatitis

Hyperglycemia

• Pleural Infiltrates and 💧Distress
• ARDS
• Shock • Hypovolemia hypokalemia
• DIC

Pancreatitis: Nursing Considerations

• History-treat+
• Pain Control Opioids
• Priority to provide IV fluids Monitors for Glucose levels and symptoms for shock • NPO-to and antacids to promote pancreas

Teaching: Acute Pancreatitis

Weeks avoid alcohol heavy meals . Follow the written instructions

Gall Bladder Disease

Cholecystitis: Cholelithiasis Cholangitis Cholecystectomy Cholangiogram, and Icterus and retrograde

Call Badder Disease: Cholelithiasis

Gallstone are more to occur for fat 40 year old and women Affect 💧50% of women by age 70

• Prevalence in men is 💧1/3 to 1/2 occurrence occurrence in women No treatment is required only in severity cases through

Stones in the Cholecystitis

• Cholestrol and Pigment Stones may occur

Acute Cholecystitis

Acute the gall as a as well those follow and. Burns and torsion multiple

Clinical Manifestations of Acute Cholecystitis

May radiate to middle sternum shoulder/ Nausea w/ chills and elevated WBC

Diagnostics for Acute Cholecystitis

• Ultrasound : Identifies thickening or that identified

Acute Cholecystitis: Collaborative Management

Antibiotic NPO Pain Mgmt Opioid Actigall

Gall Bladder Disease : Surgical Mgmt

Laparoscopic cholecystectomy Discharged home shortly on day of surgery ( no paralytic ileus, less pain) to 3 weeks pt at home with with them 24 tp 48 hours

Gall Bladder Disease Education to give

N&V, Anorexia, pain, distension of the abdomen, fever

Laparoscopic Cholecystectomy Teaching • Mange w heat to prevent • light w, D w/ 5lb , Diet ( slowly introduce w and report