Gastrointestinal Tract Anatomy

• The gastrointestinal tract (GIT) is roughly 7-7.9 meters (23-26 feet) long
• Extends from the mouth, through the esophagus, stomach, small and large intestines, to the rectum and anus.

Mouth

• Initial digestion (mechanical) starts here through chewing
• Around 1.5L of saliva is secreted by glands (parotid, submaxillary, and sublingual) to help lubricate food for swallowing
• Ptyalin enzyme from saliva starts digesting starches.

Esophagus

• It is located behind the trachea and heart, and in front of the spine
• About 25 cm (10 inches) long
• Is a muscular tube that passes through the diaphragm via the diaphragmatic hiatus.

Stomach

• Located in the upper left quadrant (LUQ) of the abdomen, under the liver's left lobe and the diaphragm
• It covers most of the pancreas
• Hollow, muscular organ with about 1500mL capacity
• Its function includes: food storage, digestive fluid secretion, and moving digested food (chyme) to the small intestine.
• It has 4 anatomic regions: cardia (entrance), fundus, body, and pylorus (outlet)
• The pyloric sphincter, a circular muscle, regulates movement between the stomach and small intestine.

Small Intestine

• This is the GIT's longest part, about 70m (230 ft)
• It secretes gastric fluids and absorbs nutrients
• Has 3 sections:
  • Duodenum (proximal): Includes the duodenal papilla, where liver and pancreas secretions enter for metabolism
  • Jejunum (middle)
  • Ileum (distal): Ends at the ileocecal valve, which controls the flow into the large intestine and prevents bacteria reflux; contains the vermiform appendix.

Large Intestine

• Spans from the cecum to the anus
• Includes the ascending (right), transverse (right to left), and descending (left) segments
• The sigmoid colon, rectum, and anus form the terminal part
• Absorbs water from undigested food
• Food waste is then eliminated as feces.

GIT Functions

• Break down food to molecular level for digestion
• Absorb nutrients into the bloodstream
• Eliminate undigested waste.

ASSESSMENT OF GASTROINTESTINAL SYSTEM

Common Symptoms

Nutritional Problems

• Includes sections on characteristics, associated factors, and history
• Characteristics involve 24-hour food intake, weight changes (gain/loss), and appetite information
• Associated factors include average daily food/fluid intake, dietary habits, eating conditions, and factors affecting food absorption
• History includes eating disorders and family history of digestive disorders or diabetes

Abdominal Pain

• Is a common symptom of GI disease
• Has characteristics like present illness history (COLDSPA) and referred pain
• Associated factors are meals, rest, activity, and defecation patterns
• Is impacted by chronic illnesses and family history (cancer, ulcer, IBD)

Dyspepsia (Indigestion)

• Upper abdominal discomfort related to eating, common in Gl dysfunction cases
• Characteristics are determined using C.O.L.D.S.P.A.
• Involves discomfort, fullness, bloating, early satiety, belching, heartburn, regurgitation symptoms
• Associated factors include fatty or seasoned foods and coarse vegetables
• Can occur with nausea/vomiting, diarrhea, alcohol intake, and medications (aspirin)
• Hereditary conditions (IBD, Crohn's, Ulcerative Colitis) can be factors

Nausea and Vomiting

• Nausea is a feeling of sickness which may or may not lead to vomiting (emptying stomach contents through the mouth)
• Distention can cause it in the duodenum or upper intestinal tract
• Early warning sign for a pathological process
• Can be triggered by odors, activity, anxiety, and food
• Characteristics involve timing (before/after eating), and documenting frequency, amount, color & consistency
• Associated factors include fever, headache, dizziness, diarrhea, and weight loss
• Consider family history such as cancer, ulcer or gall bladder diseases

Vomitus Types

• Color may vary and contain undigested food, blood (hematemesis), bilious material mixed with gastric juices
• Undigested food particles indicate tumor or intestinal obstructions.
• Blood (hematemesis) can be bright (arterial) or dark (venous) red
• Bilious material tastes bitter, gastric contents taste sour
• Vomitus Color:
  • Bright red: Mallory-Weiss Tear (mucosal lining laceration)
  • Coffee ground: digested blood from slow bleeding
  • Yellowish: Bile leakage or certain medications
  • Fecal contents: Intestinal obstruction

Diarrhea Characteristics

• Abnormal increase in stool frequency and liquidity
• Is when intestinal contents aren't absorbed properly
• C.O.L.D.S.P.A includes duration, stool frequency, consistency, color, quantity, blood, odor, and weight changes
• Associated factors: fever, n/v, abdominal pain, distention, antibiotics, travel, stress
• Family history: cancer, ulcerative colitis, Crohn's disease, malabsorption

Constipation Characteristics

• Stools are hard, dry, infrequent, or small
• C.O.L.D.S.P.A stool habits, color, size, change, diet
• Associated factors: periods of constipation, pain or distention, stress, activity level, use of antacids and anticholinergics
• family History: cancer, depression, metabolic disorders such as hypercalcemia, diabetes milletus nerve, hyperparathyroidism.

Dysphagia Characteristics

• Food & drink struggles to move from pharynx to stomach
• Key factors: gradual/acute onset, continuous/intermittent swallowing, solid vs. liquid
• Associated with regurgitation (common in GERD), heartburn, or sore throat?
• Related to CVA? (difficulty in swallowing).

Other G.I. Symptoms:

• Fecal Incontinence
• Jaundice
• Previous GI Disease

PHYSICAL EXAMINATION

Abdominal Assessment

• Uses the order of IAPePa (Inspection, Auscultation, Percussion, Palpation) to prevent bowel sound changes and inaccurate results
• Requires patient to be supine with knees flexed slightly
• Abdomen divided into 4 quadrants or 9 regions

Abdominal mapping

• Right Hypochondriac: Includes Liver, Gallbladder, Right Kidney, Small intestine
• Epigastric Region: Includes Stomach, Liver, Pancreas, Duodenum, Spleen, Adrenal Glands
• Left Hypochondriac: Includes Spleen, Colon, Left Kidney, Pancreas
• Right Lumbar: Includes Gallbladder, Liver Right Colon
• Umbilical Region: Includes Umbilicus (navel), parts of the small intestine, Duodenum
• Left Lumbar: Includes Descending Colon, Left Kidney
• Right Iliac: Includes Appendix, Cecum
• Hypogastric Region: Includes Urinary Bladder, Sigmoid Colon, Female Reproductive Organs
• Left Iliac: Includes Descending Colon, Sigmoid Colon

Inspection

• Note skin changes, lesions, nodules ulcerations, scarring, discolorations, inflammation, bruising, or striae.
• Symmetry, bulging, distention, or peristaltic waves.
• Contours of anterior abdominal wall.

Auscultation

• Precedes percussion/palpation to avoid bowel sound changes.
• Character, location, frequency of bowel sounds and vascular sounds.
  • Use diaphragm (high pitch) for bowel sounds (soft clicks/gurgles)
  • Presence of friction rubs (liver/spleen during respiration).
  • Borborygmus (loud, prolonged gurgle).
  • Use bell (low pitch) for bruit
• Bowel sounds: normal, hyperactive, hypoactive, or absent.

Percussion:

• Frequency, density, and size of the abdominal organs.
• Presence of air-filled, fluid-filled, or solid masses.
• Evaluate peritoneal irritation (light percussion).
• Assess tympani (air in stomach/small intestine) and dullness (organs/masses).

Palpation:

• Light to identify tenderness and resistance.
• Deep to identify masses.

Rectal Inspection and Palpation

• Evaluate the terminal portions of the GIT, rectum, perianal region, and anus
• Rectum (distal portion) and anus (terminal portion).
• Requires gloves, lubricant, pen light, drapes
• Position: knee-chest or left lateral with hips/knees flexed
• Spread buttocks to inspect, palpate for tone/nodules.
• Proper technique, positioning, and pleasant visualization.

Key Findings to Recognize

• Tenting of the skin from dehydration
• Mouth lesions, missing teeth, swollen/bleeding gums from nutritional deficiency.
• Body weight changes indicative of obesity/anorexia
• Palpable mass indicates enlarged organ, inflammation, malignancy, or hernia
• Rebound tenderness, guarding, rigidity indicates appendicitis, cholecystitis duodenal ulcer.
• Protuberant/bulging abdomen/flanks indicate ascites;
• Distention and absent bowel sounds indicate intestinal obstruction

Stool Characteristics - Abnormalities

• Stool varies based on the disorder; normal stool is light/dark brown
• Diseases, foods, and medications affect stool color
• Leafy vegetables (green), beets (red), medications (black) affect stool color.
• Blood presents in various ways and require investigation:
  • Melena (tarry-black from upper GIT).
  • Bright/dark red (lower GIT/rapid transit).
  • Streaks of blood (lower rectal/anal bleeding).
• Other abnormalities:
  • Steatorrhea (bulky, foul, greasy stools with high fat content).
  • Light gray stool and biliary Obstruction is decreased conjugated bilirubin
  • Presence of mucus/pus (chronic ulcerative colitis).
  • Small, hard masses with possible blood streaks (spastic colon syndrome)

DIAGNOSTIC TESTS: PREPARATION

• Fasting, laxatives, enema, contrast agent (barium swallow/enema)

A. Blood Tests

• Ordered initially with a wide range of tests
• Includes Complete Blood Count, Liver Function Test, Complete Metabolic Panel * includes determining the sodium, potassium, magnesium, electrolytes, and Prothrombin Time (PT) / Partial Thromboplastin Time (PTT)
• Triglycerides, Amylase, Lipase tests
• Carcinoembryonic Antigen (CEA) ** to determine cancer.
• CA 19-9 ** tumor marker for Gl tract cancer.
• Nursing considerations: check PCP's preferences and lab protocols

Stool

• Stool assessment can determine/diagnose G.I. disorders
• Basic inspection include assessing consistancy and color.
• Fecal urobilinogen determine the presence of bilirubin in the stool, diminished Urobilinogen may indicate an obstructive jaundice.
• Nursing responsabilities include measuring fecal fat, looking for bacteria/parasites/pathogens, identify leukocytes, test FOBT

Hemoccult Guaiac Test (FOBT)

• Detects occult blood with Guaiac
• Early screening for Gl tract cancers
• Nursing responsibilities: Do not hemoroidal bleeding
• 3 days before the test: Instruct the client to take a high fiber diet - Avoid red meats. - Avoid Aspirin + NSAIDS - Avoid high peroxidase foods - Avoid iron - Avoid laxatives/enemas/rectal suppositories - Do not give vit C

C. Breath Tests

• Diagnose digestive problems (SIBO and IBD)

Hydrogen Breath Test

• Diagnoses small intestinal bacterial overgrowth (SIBO) and inflammatory bowel diseases (IBD)
• Evaluates carbohydrate absorption
• Measures hydrogen after production in the colon (galactose and bacteria byproduct)

Urea Breath Test

• To detect H. Pylori (bacteria that lives in the mucosal lining of the stomach which can cause peptic ulcer disease.)

Procedure:

• Pt. ingests capsule of carbon-labeled urea
• Breath sample taken after 10-20 mins determining H. Pylori presence via carbon dioxide measurement
• Monitor LOC, orientation, ambulation after sedation
• Nursing Considerations:*
• Avoid antibiotics/bismuth subsalicylate 1 month prior (for diarrhea, indigestion, heartburns)
• Avoid proton pump inhibitors 2 weeks prior (can kill H. Pylori with other drugs)
• Avoid H2 blockers 24 hours prior (depresses hydrochloric acid production)
• NPO for 4-6 hours before, do not smoke 2 hours beforehand.

Radiology and Imaging Studies

• X-rays
• Contrast Studies
• CT scan
• MRI
• Positron Emission Tomography (PET) Scan
• Scintigraphy
• Radionuclide Imaging
• Virtual Colonoscopy

Upper Gl Fluoroscopy includes Barium Swallow Examination

• X-ray exam of upper Gl tract
• After contrast agent (Barium Sulfate) to detect functional/anatomic disorders; identify ulcers, tumors, regional enteritis, IBD.
• Multiple x-ray images during the procedure.
• Nursing consideration: Reduce anxiety, Low-residue diet for 2-3 days, NPO after midnight.
• Narcotic withhold because of the effect of the acetylcholine.
• Pt stool light of color, and increase fluid. Notify patient to drink more fluid to notify PCP.

Lower Gl Fluoroscopy includes Barium Enema

• Involves large intestine, rectum, and anus visualization.
• Is performed post rectal installation of barium solution.
• Detecting any polyps, tumors, and lesions of the LGIT
• The patient will be undergoing Empyting and cleanings of the bowels.
• Nursing considerations: Instruct patient on diet, NPO. Post Barium; encourage fluid intake and monitor regular stools.
• Do not administer Barium enema if there is active inflammatory diseases of the colon, intestinal obstructions

Abdominal Ultrasonography

• High frequency of the sound waves in the abdominal organs
• Detecting Enlarged gallbladder/pancreas, Gallstones, Enlarged varies, ectopic pregnacies, appendicitis
• UTZ cannot inspect through the examination behind
• Advantages of use:*
• There are very few side effects
• The cost is low
• There is no ionizing radiation.
• Nursing actions: NPO and no fat. Barium is not used for UZT

Endoscopic Procedure

• Tube/fiberoptic endoscope insertion (mouth or rectum)
• Purpouses: biopsy, removal of polyps and objects, control bleeding, opening strictures. Types of procedures: Esophagogastroduodenoscopy (EGD)/Fibroscopy ,Colonoscopy, anoscopy, proctoscopy, sigmoidoscopy ,Small bowel enteroscopy, Endoscopy through an ostomy

Upper GI Tract Endoscopy: Fibroscopy / Esophagogastroduodenoscopy (EGD).

= allows direct visualization of the esophagus, stomach, duodenum (or duodenal mucosa through a lighted endoscope or gastroscope). = evaluate Gl motility, collect secretions and tissue specimen for analysis.

Endoscopic Retrograde Cholangiopancreatography (ERCP).

= Uses endoscope in combination of series of x-ray. Allows viewing CBD = evaluate the jaundice pancreatitis, tumors, biliary tract = Nursing considerations:

• NPO before (8 hours);
• administer sedatives (Midazolam), Atropine, Glucagon given to lower gag the reflex.
• Side Lying

Lower G.I. Tract Endoscopy

• Evaluate diarrhea, fecal incontinence, hemorrhage. Observe abnormalities
• Bowel prep w/ warm tap water of fleet enema, Sedation is not needed
• Rectal bleeding and signs of intestinal perforation,

Fiberoptic Colonoscopy: Used to view the LGIT

• Diagnostic (biopsies, removal of polyps), tissue eval
• Remove polyps; prevent colon cancer; treat bleeding/strictures; bowel decompression
• Potential complications: fluid overload, vagal reactions, low blood sugar
• secure consent, limit diet, NPO post-midnight Split-dose regimen - a take as the instructions are given.
• Not performed if with documented colon perforation, Special precaution on pts w/implantable defibrillators and pacemakers #3 Laparoscopy (Peritoneoscopy)
• Procedure that is minimally invasive
• Fiber optic
• Uses an small inscision located laterally (near the umbilicus) purposes are to use test diagnostically
• Id growth, and abnormalities