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Questions and Answers
What is the primary function of Kupffer cells in the liver?
What is the primary function of Kupffer cells in the liver?
What is the role of the gallbladder in digestion?
What is the role of the gallbladder in digestion?
Which statement correctly describes unconjugated bilirubin?
Which statement correctly describes unconjugated bilirubin?
What is one of the primary components of bile?
What is one of the primary components of bile?
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Which statement is true about the upper gastrointestinal series?
Which statement is true about the upper gastrointestinal series?
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What type of cells in the pancreas secrete insulin?
What type of cells in the pancreas secrete insulin?
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What does stercobilinogen contribute to in the human body?
What does stercobilinogen contribute to in the human body?
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What is the primary purpose of a lower gastrointestinal series?
What is the primary purpose of a lower gastrointestinal series?
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What role does leptin play in appetite regulation?
What role does leptin play in appetite regulation?
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Which structure serves as a barrier preventing the reflux of gastric contents into the esophagus?
Which structure serves as a barrier preventing the reflux of gastric contents into the esophagus?
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What is the purpose of the rugae in the stomach?
What is the purpose of the rugae in the stomach?
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Which glands produce saliva in the oral cavity?
Which glands produce saliva in the oral cavity?
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Which part of the stomach is involved in guarding the exit from the stomach?
Which part of the stomach is involved in guarding the exit from the stomach?
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What mechanical action is primarily involved in the swallowing process?
What mechanical action is primarily involved in the swallowing process?
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What is the primary function of the tongue in the oral cavity?
What is the primary function of the tongue in the oral cavity?
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What is contained in saliva that aids in digestion?
What is contained in saliva that aids in digestion?
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What is a characteristic manifestation of hepatic encephalopathy?
What is a characteristic manifestation of hepatic encephalopathy?
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What might precipitate hepatic encephalopathy in a patient?
What might precipitate hepatic encephalopathy in a patient?
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Which option best describes the behavior seen in patients with hepatic encephalopathy?
Which option best describes the behavior seen in patients with hepatic encephalopathy?
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What is a common sign of impaired motor function in hepatic encephalopathy?
What is a common sign of impaired motor function in hepatic encephalopathy?
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When should planning for transfer to a transplant center begin in patients with hepatic encephalopathy?
When should planning for transfer to a transplant center begin in patients with hepatic encephalopathy?
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What is the musty, sweet odor of a patient's breath in hepatic encephalopathy commonly referred to as?
What is the musty, sweet odor of a patient's breath in hepatic encephalopathy commonly referred to as?
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What should be avoided to protect renal function in patients with liver failure?
What should be avoided to protect renal function in patients with liver failure?
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What is the treatment of choice for patients with acute liver failure?
What is the treatment of choice for patients with acute liver failure?
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Which drug is NOT commonly associated with causing acute liver failure?
Which drug is NOT commonly associated with causing acute liver failure?
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What is the primary clinical manifestation observed first in acute liver failure?
What is the primary clinical manifestation observed first in acute liver failure?
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Which laboratory test is essential for diagnosing complications associated with acute liver failure?
Which laboratory test is essential for diagnosing complications associated with acute liver failure?
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How does ammonia contribute to the neuropsychiatric manifestations of liver disease?
How does ammonia contribute to the neuropsychiatric manifestations of liver disease?
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Which type of hepatitis virus is the second most common cause of acute liver failure?
Which type of hepatitis virus is the second most common cause of acute liver failure?
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What imaging technique is used to assess liver size and the presence of ascites in acute liver failure?
What imaging technique is used to assess liver size and the presence of ascites in acute liver failure?
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Which of the following conditions can result as a complication of acute liver failure?
Which of the following conditions can result as a complication of acute liver failure?
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Which of the following best describes the onset of acute liver failure?
Which of the following best describes the onset of acute liver failure?
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What is the purpose of NG suction in the management of patients with acute pancreatitis?
What is the purpose of NG suction in the management of patients with acute pancreatitis?
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Which surgical procedure is typically performed urgently when acute pancreatitis is related to gallstones?
Which surgical procedure is typically performed urgently when acute pancreatitis is related to gallstones?
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What is a common cause of chronic pancreatitis?
What is a common cause of chronic pancreatitis?
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In chronic pancreatitis, which of the following changes occurs in the pancreas?
In chronic pancreatitis, which of the following changes occurs in the pancreas?
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What is the most common cause of obstructive pancreatitis?
What is the most common cause of obstructive pancreatitis?
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What is often a significant risk factor in patients who develop chronic pancreatitis without an identifiable cause?
What is often a significant risk factor in patients who develop chronic pancreatitis without an identifiable cause?
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Which condition is often associated with chronic pancreatitis due to inflammation?
Which condition is often associated with chronic pancreatitis due to inflammation?
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What clinical manifestation is common in both acute and chronic pancreatitis?
What clinical manifestation is common in both acute and chronic pancreatitis?
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What is the primary purpose of the adjustable gastric band (AGB)?
What is the primary purpose of the adjustable gastric band (AGB)?
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Which of the following statements about Vertical Sleeve Gastrectomy is true?
Which of the following statements about Vertical Sleeve Gastrectomy is true?
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What characteristic of Roux-en-Y Gastric Bypass makes it a combination of restrictive and malabsorptive surgery?
What characteristic of Roux-en-Y Gastric Bypass makes it a combination of restrictive and malabsorptive surgery?
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What is a potential complication that should be monitored post-surgery in bariatric patients?
What is a potential complication that should be monitored post-surgery in bariatric patients?
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What nursing action is crucial to prevent pulmonary complications after bariatric surgery?
What nursing action is crucial to prevent pulmonary complications after bariatric surgery?
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Which surgical approach is recommended for patients who are at surgical risks?
Which surgical approach is recommended for patients who are at surgical risks?
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What should a patient expect regarding postoperative equipment after bariatric surgery?
What should a patient expect regarding postoperative equipment after bariatric surgery?
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How does the adjustable gastric band provide long-term weight management?
How does the adjustable gastric band provide long-term weight management?
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Study Notes
Gastrointestinal (GI) System
- Also called the digestive system
- Consists of the GI tract and its associated organs and glands
- Includes the mouth, esophagus, stomach, small intestine, large intestine, rectum, and anus
Structures and Functions of the Gastrointestinal System
- The GI tract extends approximately 30 feet (9 meters) from the mouth to the anus
- Composed of four common layers: mucosa, submucosa, muscle, and serosa
- The muscular coat consists of two layers: the circular (inner) layer and the longitudinal (outer) layer
- Innervated by the parasympathetic and sympathetic branches of the autonomic nervous system
- Parasympathetic (cholinergic) system is mainly excitatory
- Sympathetic (adrenergic) system is mainly inhibitory
Location of Organs of the Gastrointestinal System
- Diagram of the GI system with labeled organs (e.g., stomach, small intestine, colon)
- Diagram illustrating the different parts of the stomach (e.g., fundus, body, antrum)
Peritoneum
- Abdominal organs are almost completely covered by the peritoneum
- Two layers of the peritoneum: parietal layer (lines the abdominal cavity wall), and visceral layer (covers the abdominal organs)
- Two folds of the peritoneum are the mesentery and the omentum
- Mesentery attaches the small and part of the large intestine to the posterior abdominal wall
- Contains blood and lymph vessels
- Omentum hangs like an apron from the stomach to the intestines
- Contains fat and lymph nodes
Function of the GI System
- The main function is to supply nutrients to body cells.
- This is accomplished through the processes of ingestion (taking in food), digestion (breaking down food), and absorption (transferring food products into circulation).
- Elimination is the process of excreting waste products.
Ingestion
- Ingestion is the intake of food
- Appetite center is located in the hypothalamus
- Hypoglycemia, an empty stomach, a decrease in body temperature, and input from higher brain centers stimulate the appetite center
- The hormone ghrelin, released from the stomach mucosa, plays a role in appetite stimulation
- Another hormone, leptin, is involved in appetite suppression
- The sight, smell, and taste of food frequently stimulate appetite
- Deglutition (swallowing) is the mechanical component of ingestion
- Organs involved: mouth, pharynx, and esophagus
- Mouth: oral cavity contains teeth (mastication) and the tongue
- Pharynx: epiglottis closing over the larynx during swallowing
- Oropharynx: provides a route for food from the mouth to the esophagus
- Esophagus: Muscular layers contract (peristalsis) and propel food to the stomach. Upper esophageal sphincter (UES) at the proximal end, and the lower esophageal sphincter (LES) at the distal end. The LES remains contracted except during swallowing, belching, or vomiting
Digestion and Absorption
- Stomach: stores food, mixes food with gastric secretions, empties contents in small boluses into the small intestines.
- The stomach absorbs only small amounts of water, alcohol, electrolytes, and certain drugs.
- Stomach always contains gastric fluid and mucus.
- Fundus (cardia), body, and antrum are three main parts of the stomach
- Pylorus: small portion of the antrum proximal to the pyloric sphincter
- Sphincter muscles (the LES and the pyloric sphincter) guard the entrance to and exit from the stomach.
- The serous (outer) layer of the stomach is formed by the peritoneum.
- Muscular layer of stomach: longitudinal (outer), circular (middle), and oblique (inner) layers.
- Mucosal layer forms folds called rugae that contain chief cells (secrete pepsinogen) and parietal cells (secrete hydrochloric acid (HCl), water, and intrinsic factor).
- HCl acid makes gastric juice acidic to protect against ingested organisms.
- Intrinsic factor promotes cobalamin (vitamin B12) absorption in the small intestine
- Small Intestine: two primary functions - digestion and absorption (uptake of nutrients from the gut lumen to the bloodstream)
- Extends from the pylorus to the ileocecal valve
- Composed of the duodenum, jejunum, and ileum
- Ileum: prevents reflux from the large intestine
- Digestive enzymes on the brush border of microvilli chemically break down nutrients
- Villi surrounded by crypts of Lieberkühn (multipotent stem cells for other cell types)
- Brunner's glands in the duodenum submucosa secrete bicarbonate.
- Intestinal goblet cells secrete mucus to protect the mucosa
- Table of Gastrointestinal secretions and their actions (e.g., salivary amylase, pepsinogen, HCI acid, lipase, intrinsic factor, enzymes from the small intestine, and liver/gallbladder bile).
Elimination
- Large Intestine: most important function is absorption of water and electrolytes. Forms feces, serves as a reservoir for fecal mass, and enables defecation.
- Microorganisms in the colon break down proteins not digested or absorbed in the small intestine
- Deaminate amino acids, producing ammonia, converted to urea by liver, and excreted by the kidneys.
- Synthesize vitamin K and some B vitamins.
- Contribute to flatus production.
- The defecation reflex is initiated when feces enter the rectum. Sensory nerve ending produce the desire to defecate.
- The reflex center for defecation is located in the sacral portion of the spinal cord.
Liver
- Functional units of the liver are lobules
- Lobules consist of rows of hepatic cells (hepatocytes) arranged around a central vein
- Capillaries (sinusoids) located between the rows of hepatocytes and lined with Kupffer cells.
- Kupffer cells carry out phagocytic activity (removing toxins and bacteria from blood).
- Table listing the functions of the liver (e.g., glycogenesis, glycogenolysis, gluconeogenesis, synthesis of plasma proteins, formation of urea, fat metabolism, detoxification, steroid metabolism)
- Bile production, excretion, and storage (bile salts, pigments like bilirubin, and cholesterol)
- Breakdown of old red blood cells (RBCs) into bilirubin and biliverdin. Albumin and other proteins formation
Biliary Tract
- System consisting of the gallbladder and duct system. The gallbladder is a pear-shaped sac located below the liver.
- Concentrates and stores bile created by the liver.
- Bilirubin is reduced to stercobilinogen and urobilinogen. Bilirubin is reduced to a water-soluble form by the liver.
- Stercobilinogen is the main component of stool color.
- Bilirubin metabolism, a breakdown of hemoglobin, is continuously produced. It is insoluble in water and must be bound to albumin for transport to the liver, where it is conjugated with glucuronic acid. This conjugated bilirubin is soluble and is excreted in bile.
Pancreas
- has both exocrine (producing and releasing enzymes) and endocrine functions. Endocrine functions occur in the islets of Langerhans (beta cells secrete insulin and amylin, alpha cells secrete glucagon, delta cells secrete somatostatin, and F cells secrete pancreatic polypeptide).
Diagnostic Tests
- Radiologic studies
- Upper gastrointestinal series: fluoroscopy, barium solution to visualize esophagus, stomach, and small intestine (useful for esophageal strictures, polyps, tumors, hiatal hernias, foreign bodies, and peptic ulcers)
- Lower gastrointestinal series (barium enema): visualization of colon using fluoroscopy and X-rays, identifying polyps, tumors, and lesions.
- Virtual colonoscopy: CT or MRI scanning with computer software to produce images of the colon and rectum, identifying polyps and the necessity of a conventional colonoscopy for biopsy/removal
- Endoscopy: direct visualization of body structures through a lighted fiberoptic instrument (e.g., esophagus, stomach, duodenum, colon, pancreatic, hepatic, and common bile ducts - endoscopic retrograde cholangiopancreatography (ERCP).
- Liver biopsy: obtaining hepatic tissue to establish diagnoses or assess fibrosis or following liver disease progress (e.g., chronic hepatitis).
- Serum tests (e.g., bilirubin, protein, and specific liver enzyme tests)
Intraabdominal Hypertension and Abdominal Compartment Syndrome
- Intraabdominal Hypertension (IAH): a steady-state pressure concealed within the abdominal cavity
- IAH is diagnosed when three documented Intra-abdominal Pressure (IAP) measurements are 12-20 mm Hg, four to six hours apart
- Without treatment, it can progress to Abdominal Compartment Syndrome.
- Normal IAP: 5 mmHg
- Critically ill patients: 5-7 mmHg
- Obese patients: 15 mmHg
- Complication of emergency repairs of abdominal aortic aneurysms
- Persistent IAH reduces blood flow to viscera
Acute Liver Failure
- Fulminant hepatic failure is a clinical syndrome characterized by severe impairment of liver function
- Associated with hepatic encephalopathy
- Most common cause: drugs (e.g., acetaminophen, in combination with alcohol)
- People with alcohol abuse are particularly susceptible to the detrimental effects of acetaminophen on the liver
- Other drugs: isoniazid, halothane, sulfa-containing drugs, and NSAIDs
- Viral hepatitis (Hepatitis B virus [HBV]) as the second most frequent cause of acute liver failure (Hepatitis A is less common)
- Symptoms of jaundice, coagulation abnormalities, and encephalopathy. Changes in mentation are the first clinical sign
- Complications include cerebral edema, renal failure, hypoglycemia, metabolic acidosis, sepsis, and multiorgan failure
- Additional studies: Serum bilirubin is elevated and prothrombin time is prolonged
- Liver enzyme levels (AST, ALT) usually markedly elevated, blood chemistries, complete blood counts (CBCs), acetaminophen level, viral hepatitis serologies, serum levels (a1-antitrypsin, iron levels, and autoantibodies), and CT or MRI for assessment of liver size and contours
Acute Pancreatitis
- Acute inflammation of the pancreas
- Mild edema to severe hemorrhagic necrosis variations in inflammation
- Risk factors: gallbladder disease, chronic alcohol illness, smoking (independent risk factor for other conditions)
- Biliary sludge (cholesterol and calcium salt crystals)
- Other causes: trauma, viral infections (mumps, coxsackievirus B, HIV), penetrating duodenal ulcer, cysts, abscesses, cystic fibrosis, Kaposi sarcoma, certain drugs (corticosteroids, thiazide diuretics, oral contraceptives), metabolic disorders (hyperparathyroidism), renal failure, and vascular diseases
- Most common pathogenic mechanism: pancreatic autodigestion
- Trypsinogen activated to trypsin by enterokinase. Trypsin is an inactive proteolytic enzyme.
- In pancreatitis, activated trypsin digests the pancreas and produces bleeding.
- Mechanisms of chronic alcohol intake in pancreatitis unknown (increases digestive enzymes production)
- Pathophysiology involvement is classified as mild (edematous or interstitial pancreatitis) or severe (necrotizing pancreatitis)
- Clinical Manifestations: abdominal pain, peritoneal irritation, and biliary tract obstruction
- Back pain radiating to mid-epigastrium
- Other symptoms: abdominal tenderness, decreased or absent bowel sounds, paralytic ileus, lung involvement (crackles), skin discoloration (Grey Turner's spots or Cullen's sign)
- Complications: varying severity depending on pancreatic destruction (complete recovery, recurring attacks, chronic pancreatitis), potentially life-threatening
- Pancreatic pseudocyst: accumulation of fluid, pancreatic enzymes, tissue debris, and inflammatory exudates surrounded by a wall
- Pancreatic abscess: collection of pus, extensive necrosis, and infection
- Systemic complications: pulmonary (pleural effusion, atelectasis, pneumonia, ARDS), cardiovascular (hypotension) complications, tetany (hypocalcemia).
- Complications can be linked to the passage of exudates from the peritoneal cavity through transdiaphragmatic lymph channels and enzyme-induced inflammation of the diaphragm.
- Diagnostic studies: serum amylase/lipase usually elevated for 24–72 hours, abdominal ultrasound, x-ray; contrast-enhanced CT scan, ERCP(can cause acute pancreatitis), magnetic resonance cholangiopancreatography (MRCP), angiography, and chest X-rays
- Collaborative care: relief of pain, preventing shock, reducing pancreatic secretions, correcting fluid/electrolyte imbalances, preventing infections, and removing precipitating causes
- Treatment methods: aggressive hydration, pain management, minimizing pancreatic stimulation, and using IV morphine and pain medications together with an antispasmodic agent (atropine and anticholinergics avoided in paralytic ileus), blood volume replacements, and electrolyte solutions.
Chronic Pancreatitis
- Continuous, prolonged, inflammatory, and fibrosing process of the pancreas
- Progressive destruction as replaced by fibrotic tissue
- Risk factors: alcohol abuse, obstruction, cholelithiasis, tumors, trauma, systemic diseases (e.g., systemic lupus erythematosus), autoimmune pancreatitis, and cystic fibrosis
- Etiology/causes: inflammation of the sphincter of Oddi (associated with cholelithiasis, cancer), and nonobstructive pancreatitis
- Clinical manifestations: abdominal pain, often chronic, recurrent attacks, may become almost constant, location similar to acute pancreatitis, described as heavy, gnawing, burning, cramplike, not relieved by food
- Other symptoms: pancreatic insufficiency (weight loss, constipation, mild jaundice, dark urine, steatorrhea, diabetes mellitus), fatty stools
- Diagnostic studies: serum amylase and lipase, mild leukocytosis, elevated sedimentation rate
- Stool samples for fat content, deficiencies, glucose intolerance
- Collaborative care: analgesics, pancreatic enzyme replacement, controlled diabetes, low-fat diet, avoidance of alcohol and caffeinated beverages
- Treatment: endoscopic therapy or surgery (choledochojejunostomy, Roux-en-Y pancreatojejunostomy), which involves diverting bile flow, relieves ductal obstruction
- Drugs: acid-neutralizing drugs (e.g., antacids), inhibitors (e.g., H2-receptor blockers or proton pump inhibitors)
Bariatric Surgery
- Surgery is the only treatment for sustained weight loss
- Criteria: BMI of 40 kg/m2 or BMI of 35 kg/m2 with complications (e.g., hypertension, type 2 diabetes mellitus, heart failure, sleep apnea)
- Contraindications: untreated depression, binge eating disorders, drug abuse, cancer, end-stage kidney, liver, or cardiopulmonary disease, severe coagulopathy, or inability to comply with nutritional recommendations.
Categories of Bariatric Surgeries
- Restrictive surgeries, reducing stomach size (adjustable gastric banding, vertical sleeve gastrectomy), these surgeries do not alter digestion
- Malabsorptive surgeries (biliopancreatic diversion with or without duodenal switch), which significantly reduce the bowel length to reduce absorption of nutrients
Diabetes Mellitus
- Group of metabolic diseases characterized by increased blood glucose levels
- Defectives in insulin secretion, insulin action or both
- Types:
- Type 1: destruction of pancreatic beta cells, absolute insulin deficiency, prone to ketoacidosis
- Type 2: relative lack of insulin receptors or resistance to insulin action, commonly occurs in people over age 30, prone to hyperosmolar, hyperglycemic syndrome
- Gestational: any degree of glucose intolerance during pregnancy, caused by placental hormones
- Predisposing factors: genetic predisposition, viruses, pancreatitis, pancreatic tumors, autoimmune diseases, and obesity
- Risk factors: ethnicity, age ≥45, previous impaired fasting glucose/impaired glucose tolerance, hypertension, low HDL, high triglycerides, history of gestational diabetes
- Manifestations: polyuria, polydipsia, weight loss, blurred vision, recurrent infections, weakness, paresthesia, nausea, vomiting, abdominal pain
Diagnostic Tests
• Fasting plasma glucose • Random plasma glucose • 2-hour postload glucose • Oral glucose tolerance test (OGTT) • Glycosylated hemoglobin A1c (HbA1c)
Diabetes Management
- Components: education, nutritional management, exercise, pharmacologic therapy, and monitoring.
- Diet: individualized meal plan, balanced diabetic diet (50% carbohydrates, 30% fats, 20% protein)
- Exercise: regular patterns, assess blood glucose before, during and after (15g carbohydrate snack)
- Medications: oral hypoglycemic agents (first and second generation sulfonylureas,) biguanides, alpha-glucosidase inhibitors, non-sulfonylurea insulin secretagogues, thiazolidinediones, insulin,
Insulin Therapy
- Methods: traditional subcutaneous injections, insulin pens, jet injectors, insulin pumps.
- Injection sites: abdomen, arms, thighs, buttocks.
- Mixing insulin: introduce air into the vial of intermediate-acting insulin, then draw up regular insulin, then draw up the intermediate-acting insulin
Complications of Insulin Therapy
- Local/systemic reactions (e.g., edema, desensitization)
- Lipodystrophy (lipoatrophy, lipohypertrophy)
- Resistance to insulin
- Dawn phenomenon
- Somogyi effect
- Insulin waning
Hypoglycemia
- Occurs when blood glucose falls to less than 70 mg/dL
- Causes: overdose of insulin or oral hypoglycemic agents, omission of meals, strenuous exercise, gastrointestinal upset
- Manifestations: sweating, tremor, pallor, tachycardia, headache, light-headedness, and confusion, numbness/tingle of lips/tongue, slurred speech, drowsiness, seizures, coma
- Management: simple sugar orally if conscious, Glucagon (SQ or IM) if unconscious, carbohydrates, glucose IV
Diabetic Ketoacidosis (DKA)
- Absence or markedly inadequate amount of insulin
- Life-threatening complication of type 1 diabetes
- Clinical features: hyperglycemia, dehydration, electrolyte loss, acidosis
- Pathophysiology: increased protein catabolism, increased gluconeogenesis, inefficient glucose utilization, increased ketone bodies production, osmotic diuresis, dehydration, electrolyte imbalances, shock, and tissue hypoxia
- Manifestations: polyuria, thirst, nausea, vomiting, abdominal pain, weakness, headache, fatigue, dim vision, dehydration, hypovolemic shock, hyperpnea, acetone breath, lethargy, coma, blood glucose >300-800 mg/dL
- Interventions: regular insulin IV push, IV fluids (0.9% NaCl 1 L first hour, 2-8 L over 24 hrs), sodium bicarbonate (correct acidosis), monitor electrolytes, especially serum potassium(K+), replace potassium, hourly monitoring of urine output (30 mL/hr)
Hyperosmolar Hyperglycemic Syndrome (HHS)
- Metabolic disorder of type 2 diabetes
- Resulting from relative insulin deficiency
- Without ketosis and acidosis
- Precipitating factors: infection, renal failure, myocardial infarction, cerebrovascular accident, gastrointestinal hemorrhage, pancreatitis, congestive heart failure, total parenteral nutrition, and steroid use.
- Pathophysiology: insulin deficiency, increased glucose production, impaired glucose utilization, osmotic diuresis, dehydration, hypovolemia, tissue hypoxia, lactic acidosis
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