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Digestive System NURS 242 Copyright © 2017, 2021 Elsevier Inc. All rights reserved. 2 Objectives 1 2 3 Identify organs of the GI system and their function Describe the pathophysiology of common GI disorders Describe the clinical manifestations of common GI disorders 3 Gastrointestinal Tract (Cont.)...
Digestive System NURS 242 Copyright © 2017, 2021 Elsevier Inc. All rights reserved. 2 Objectives 1 2 3 Identify organs of the GI system and their function Describe the pathophysiology of common GI disorders Describe the clinical manifestations of common GI disorders 3 Gastrointestinal Tract (Cont.) 4 Gastrointestinal Tract: Purposes Ingestion of food Propulsion of food and wastes from the mouth to the anus Secretion of mucus, water, and enzymes Mechanical digestion of food particles Chemical digestion of food particles Absorption of digested food Elimination of waste products by defecation Immune and microbial protection against infection Take-aways Alterations in digestion And/or absorption 5 Swallowing Phases Oropharyngeal Food formed into bolus and forced toward pharynx Pharynx contracts Respiration inhibited and epiglottis slides down Esophageal Food bolus enters esophagus Esophagus relaxes Peristalsis occurs to move food down to lower esophageal sphincter Food bolus enters stomach Problems with swallowing (dysphagia) can occur in either phase 6 Gastric Motility Swallowing Causes relaxation Facilitated by gastrin and cholecystokinin Motilin (in small intestine) Secretin (in duodenum) Increases peristalsis Decreases peristalsis Gastric mixing and emptying Retropulsion (motility) Rate dependent on volume, osmotic pressure, and chemical composition Problems with motility are affected by alterations in swallowing and/or secretions 7 Gastric Secretion Stimulation of gastric secretion Eating Gastrin Paracrine pathways (secretion) Acetylcholine Chemicals Ethanol, coffee, protein Stimulation of gastric secretion happens from intrinsic and extrinsic stimuli 8 Gastric Secretion The stomach secretes large volumes of gastric juices Mucus Acid Enzymes Hormones Intrinsic factor Gastroferrin (in stomach – transports ferrous iron to small intestine) Intestinal Digestion and Absorption Initiated in stomach Actions of gastric hydrochloric acid and pepsin Continues in proximal portion of small intestine 9 Action of pancreatic enzymes, intestinal enzymes, and bile salts Carbohydrate breakdown Proteins degraded Fats emulsified Nutrients absorbed by active transport, diffusion, or facilitated diffusion Digestion occurs in upper GI tract and absorption in small intestine 10 Intestinal Motility The movements of the small intestine facilitate both digestion and absorption Haustral segmentation Peristalsis Ileogastric reflex Intestinointestinal reflex Gastroileal reflex Ileocecal valve Peristalsis 11 Large Intestine Motor and secretory activity regulated by enteric nervous system Vagal stimulation increases rhythmic contraction of the proximal colon Blood supply is derived primarily from branches of the superior and inferior mesenteric arteries 12 Large Intestine Colonic movement primarily segmental Fecal mass massaged Water absorbed Peristaltic movements promote the emptying of the colon Gastrocolic reflex Causes the fecal mass to pass rapidly into the sigmoid colon and rectum Defecation reflex Stimulated by the movement of feces into the sigmoid colon and rectum Large intestine mainly involves peristalsis and water absorption Immunity and the GI System Major role in immune defenses by killing many microorganisms Mucosal secretions produce antibodies (IgA) Paneth cells produce defensins and other antibiotic peptides and lysozymes important to mucosal immunity Peyer patches (collections of lymphocytes, plasma cells, and macrophages) produce immunoglobulin A as a component of the gutassociated lymph tissue in the small intestine 13 14 Numbers of bacteria increase from proximal to distal GI tract Intestinal Microbiome Multiple factors affect normal composition of bacterial flora Highest in colon Genetics, diet, environmental, drugs Alert immune system to protect against infection 15 Most nutrients are absorbed in the A. Stomach B. Transverse Colon C. Small intestine D. Large intestine 16 The nurse knows that the GI tract is innervated by the sympathetic and parasympathetic nervous systems. During a time of stress when the sympathetic nervous system is being stimulated, the nurse understand this will cause A. Decreased GI motility B. Increased GI motility C. Increased gastrin secretion D. It will not effect the GI system, it is only a neural response. 17 Intestinal Microbiome Intestinal tract Sterile at birth but colonized within a few hours Number and diversity of bacteria decrease with aging Bacteria in stomach are relatively sparse Low concentration of aerobes in duodenum and jejunum Acid kills ingested pathogens and inhibits bacterial growth Suppressed by bile acid, intestinal motility, and antibodies Anaerobes found distal to ileocecal valve but not proximal to the ileum Microbes in GI tract and increase distally are diverse 1 8 Accessory Organs of Digestion Accessory Organs of Digestion Liver Divided into right and left lobes Right lobe further divided into the caudate and quadrate lobes 19 20 Secretion of Bile Bile is an alkaline, bittertasting, yellowish green fluid that contains bile salts, cholesterol, bilirubin, electrolytes, and water Bile formed by hepatocytes and secreted into the bile canaliculi 21 Metabolism of Bilirubin Bilirubin is a byproduct of the destruction of aged red blood cells Bilirubin gives bile a greenish black color and produces the yellow tinge of jaundice Vascular and Hematologic Liver Functions Stores blood Hemostatic functions 22 Synthesizes clotting factors Because bile salts are needed for reabsorption of fats, vitamin K absorption depends on adequate bile production in the liver The liver is very vascular 23 Liver Functions Metabolism of nutrients Fats Proteins Carbohydrates Metabolic detoxification Storage of minerals and vitamins Main functions of liver: Metabolism Detox Storage 24 Gallbladder Saclike organ that lies on the inferior surface of the liver Function (of the gallbladder) is to store and concentrate bile between meals Holds about 90 mL of bile Begins to contract 30 minutes after eating under the influence of the vagus nerve and cholecystokinin Gallbladder: Storage of bile 25 Exocrine Pancreas The exocrine pancreas is composed of acinar cells that secrete enzymes and networks of ducts that secrete alkaline fluids to assist in digestion Pancreas is full of enzymes to aid in digestion GI Changes Associated With Aging Gastric mucosa atrophy Decreased peristalsis Dulled nerve impulses Distention and dilation of pancreatic ducts Decrease in number and size of hepatic cells Disruption of microbial balance of good anaerobic and aerobic flora ALTERATIONS IN DIGESTIVE FUNCTION 28 Anorexia Clinical Manifestations of Gastrointestin al Dysfunction: Definitions A lack of a desire to eat despite physiologic stimuli that would normally produce hunger Vomiting The forceful emptying of the stomach and intestinal contents through the mouth Several types of stimuli initiate the vomiting reflex The common symptoms of vomiting are hypersalivation and tachycardia 29 Clinical Manifestations of Gastrointestin al Dysfunction: Definitions Nausea Retching A subjective experience that is associated with a number of conditions Nonproductive vomiting Projectile vomiting Spontaneous vomiting that does not follow nausea or retching 30 Clinical Manifestations of Gastrointestin al Dysfunction: Definitions Constipation Defined as infrequent or difficult defecation Primary condition Normal transit (functional) Slow transit Pelvic floor or outlet dysfunction Constipation (Cont.) Secondary condition Clinical Manifestations of Gastrointestin al Dysfunction: Definitions Manifestations Caused by many different factors such as diet, medications, various disorders, aging Straining with defecation Hard stools Sensation of incomplete emptying Manual maneuvers to facilitate stool evacuation Fewer than three bowel movements per week Manage underlying disease 31 32 Case Study: Constipation Luis is a 72 y.o. Hispanic man with Parkinson Disease (PD). He was diagnosed with PD 13 years ago. He has an intermittent, resting tremor of both upper extremities and it has become increasingly difficult for him to feed himself and swallow. Finger foods have been easier to manage. Thickened liquirds are recommended, but he does not like the taste. His son reports that Luis spends a lot of time on the toilet with extraordinary time straining and very large hard stools. It has been at least 4 days since his last bowel movement. What’s possibly causing the constipation? Further information/assessment needed? Nursing diagnoses? Copyright © 2017, Elsevier Inc. All rights reserved. 33 Diarrhea Presence of loose, watery stools Clinical Manifestations of Gastrointestin al Dysfunction Definitions Acute or persistent Large-volume diarrhea Caused by excessive amounts of water or secretions or both in the intestines Infection, irritation Small-volume diarrhea Volume of feces is not increased, usually results from excessive intestinal motility Diseases of colon or rectum Irritable bowel syndrome 34 A patient is on warfarin (Coumadin) has been admitted for GI bleeding. The history and physical examination indicates that the patient may have taken too much warfarin. The nurse anticipates that the patient will receive which antidote? 1. Vitamin D 2. Vitamin K 3. Protamine sulfate 4. Magnesium Sulfate 35 Diarrhea (Cont.) Clinical Manifestations of Gastrointestin al Dysfunction: Definitions Major mechanisms of diarrhea Osmotic diarrhea Secretory diarrhea Motility diarrhea Systemic effects Dehydration Electrolyte imbalance Weight loss Associated with malabsorption syndromes Treated with fluid restoration, antimotility or waterabsorbent medications, treatment of causal factors 36 Clinical Manifestations of Gastrointestin al Dysfunction: Definitions Abdominal pain Mechanical, inflammatory, or ischemic Usually associated with tissue injury and inflammation Parietal pain Visceral pain Referred pain 37 Gastrointestinal bleeding Clinical Manifestations of Gastrointestin al Dysfunction: Definitions Upper gastrointestinal bleeding Esophagus, stomach, or duodenum Lower gastrointestinal bleeding Jejunum, ileum, colon, or rectum Occult bleeding Physiologic response depends on rate and amount of blood loss GI Concept: Disorders of Motility Dysphagia Difficulty swallowing Mechanical obstructions Functional disorders Achalasia Related to loss of inhibitory neurons in the myenteric plexus with smooth muscle atrophy in the middle and lower portions of the esophagus 38 Dysphagia Disorders of Motility Manifestations Stabbing pain at the level of obstruction Discomfort after swallowing Regurgitation of undigested food Unpleasant taste sensation Vomiting Aspiration Weight loss Symptoms managed by eating small meals slowly, taking fluid with meals, and sleeping with the head elevated to prevent regurgitation and aspiration 39 40 Disorders of Motility Exemplar: GERD Gastroesophageal reflux disease (GERD) Reflux of acid and pepsin from the stomach to the esophagus that causes esophagitis Resting tone of the LES tends to be lower than normal Conditions that increase abdominal pressure or delay gastric emptying can contribute to the development of reflux esophagitis Gastroesophageal Reflux Disease (GERD) Pathophysiology Overview Most common upper GI disorder in the U.S. Occurs as a result of backward flow of stomach contents into esophagus Hiatal hernias increase risk for GERD During healing, Barrett’s epithelium and esophageal stricture are concerns Gastroesophageal reflux disease (GERD) (Cont.) Disorders of Motility Manifestations Heartburn Acid regurgitation Dysphagia Chronic cough Asthma attacks Laryngitis Upper abdominal pain within 1 hour of eating Proton pump inhibitors are the agents of choice for controlling symptoms and healing esophagitis 42 43 Case Study: GERD A 34-year-old man visits a primary care clinic because his family says that his voice sounds hoarse and he finds that he needs to clear his throat often. During the initial visit, he tells you that he returned from military service 1 year ago and that his routine physical exam 6 months ago was normal. He is slightly overweight and currently smokes 1 pack of cigarettes a day and has done so since age 20. He denies experiencing any heartburn or regurgitation, although he has upper abdominal discomfort. He has no family history of esophageal cancer. His hoarseness has developed over the last 2 months. What is causing the symptoms? Pathophysiology? Further assessment? Medications? H2 receptor blockers, proton pump inhibitors, antacids Nursing diagnoses? Disorders of Motility Other Hiatal hernia Diaphragmatic hernia with protrusion of the upper part of the stomach through the diaphragm and into the thorax Gastroparesis Delayed gastric emptying in the absence of mechanical gastric outlet obstruction Associated with diabetes or some surgeries Symptoms include nausea, vomiting, abdominal pain, and postprandial fullness or bloating 44 45 Disorders of Motility Pyloric obstruction The blocking or narrowing of the opening between the stomach and the duodenum Can be acquired or congenital Intestinal obstruction and paralytic ileus An intestinal obstruction is any condition that prevents the flow of chyme through the intestinal lumen 46 Inflammatory disorder of the gastric mucosa Acute gastritis Gastritis Caused by injury of the protective mucosal barrier Chronic gastritis Chronic fundal gastritis (type A, immune) Chronic antral gastritis (type B, nonimmune) Symptoms vague Gastritis Pathophysiology Overview Inflammation of gastric mucosa Erosive versus nonerosive Acute versus chronic Often caused by long-term NSAID use Can be caused by H. pylori Rapid onset of epigastric pain and dyspepsia Acute gastritis Sometimes accompanied by gastric bleeding, hematemesis or melena May have few symptoms unless ulceration occurs Chronic gastritis Nausea, vomiting, upper abdominal discomfort EGD via endoscope is gold standard diagnostic tool Gastritis: Assessmen t: Recognize Cues 49 Exemplar: Peptic Ulcer Disease A break or ulceration in the protective mucosal lining of the lower esophagus, stomach, or duodenum Acute and chronic ulcers Superficial Erosions Deep Zollinger-Ellison syndrome 50 Peptic Ulcer Disease (Cont.) Duodenal ulcers Most common of the peptic ulcers Developmental factors: Helicobacter pylori infection Hypersecretion of stomach acid and pepsin Use of NSAIDs Characterized by intermittent pain in the epigastric area Relieved rapidly by ingestion of food or antacids Management aimed at relieving the causes and effects of hyperacidity and preventing complications 5 1 Duodenal Ulcer 52 Gastric Ulcer Gastric ulcers tend to develop in the antral region of the stomach, adjacent to the acid-secreting mucosa of the body Pathophysiology The primary defect is an increased mucosal permeability to hydrogen ions Gastric secretion tends to be normal or less than normal Manifestations and treatment similar to duodenal ulcers except food cause pain Complications of Ulcers Hemorrhage (most serious) Perforation Pyloric obstruction Intractable disease 54 Case Study: Peptic Ulcer Harold, a 58 year old grocery store manager, had recently been waking up in the middle of the night with abdominal pain. This was happening several nights a week. He was also experiencing occasional discomfort in the middle of the afternoon. Harold decided to schedule an appointment with his physician. Harold also indicates that his appetite had suffered as a result of the pain and fear that what he was eating may be responsible for the pain. Harold was referred for an endoscopy which revealed that Harold had a peptic ulcer. Analysis of a tissue sample taken from the site showed that Harold also had an infection that was caused by Helicobacter pylori bacteria. Risk factors for ulcer disease? Medications? Nursing diagnoses? 55 Maldigestion GI Concept: Malabsorption Syndromes Malabsorption Failure of the chemical processes of digestion Failure of the intestinal mucosa to absorb digested nutrients Maldigestion and malabsorption frequently occur together 56 Pancreatic exocrine insufficiency Insufficient pancreatic enzyme production Malabsorption Syndromes (Cont.) Lactase deficiency Inability to break down lactose into monosaccharides and therefore prevent lactose digestion and absorption Bile salt deficiency Conjugated bile salts needed to emulsify and absorb fats Fat-soluble vitamin deficiencies: Vitamins A, D, K, E Lipase, amylase, trypsin, or chymotrypsin 57 GI Concept: Inflammatory Bowel Disease: Ulcerative Colitis and Crohn Disease Ulcerative colitis and Crohn disease Chronic, relapsing inflammatory bowel disorders Genetics Environmental factors Alterations of epithelial barrier functions Altered immune reactions to intestinal flora 58 Ulcerative Colitis Chronic inflammatory disease that causes ulceration of the colonic mucosa Sigmoid colon and rectum Begins in the rectum and may extend proximally to the entire colon Intermittent periods of remission and exacerbation 59 Ulcerative Colitis (Cont.) Symptoms: Diarrhea (10 to 20/day) Urgency Bloody stools Cramping Treatment Mild to moderate disease is treated with 5aminosalicyclate therapy followed by steroids Thioprine and immunomodulatory agents or vedolizumab are used for serious disease Surgery for severe disease 60 Kyle is a 28-year-old young man who is experiencing lower abdominal discomfort and frequent diarrhea (more than 15 bowel movements per day). Kyle reports that he has experienced episodes of loose stool, but it seems to be getting worse. He also reports having lost 15 pounds in the past month. His physician instructs him to visit a gastroenterologist for a colonoscopy. The colonoscopy reveals inflammation in the rectum, sigmoid colon, ascending colon, and ileum. These findings support what diagnosis? 61 Case Study: Ulcerative Colitis CP is a 26 y.o. female that was diagnoses with ulcerative colitis in 2011. She reports that about once a month she has episodes of bloody diarrhea with abdominal distention, nausea, and cramping. She also complains of fatigue. Her BMI is 18. Further assessment data? Nursing diagnoses? 62 Crohn Disease Granulomatous colitis, ileocolitis, or regional enteritis Idiopathic inflammatory disorder; affects any part of the digestive tract, from mouth to anus 63 Crohn Disease (Cont.) Causes “skip lesions” One side of the intestinal wall may be affected and not the other Ulcerations can produce fissures that extend into the lymphatics Symptoms similar to ulcerative colitis Anemia may result from malabsorption of vitamin B12 and 12 folic acid Treatment similar to ulcerative colitis 64 Irritable Bowel Syndrome Symptom-based disease characterized by recurrent abdominal pain with altered bowel habits More common in females Associated with anxiety, depression, and reduced quality of life 65 Irritable Bowel Syndrome (Cont.) Cause unknown but mechanisms proposed Visceral hypersensitivity Abnormal intestinal permeability, motility, and secretion Postinflammatory Alteration in gut microbiota Food allergy/intolerance Psychosocial factors Most common digestive disorder Irritable Bowel Syndrome (IBS) One in five people in the U.S. Classifications IBS-D (diarrhea) IBS-C (constipation) IBS-A (alternating diarrhea/constipation) IBS-M (mix of diarrhea/constipation) Etiology: Unclear 67 Manifestations Irritable Bowel Syndrome (Cont.) Lower abdominal pain or discomfort and bloating Symptoms are usually relieved with defecation and do not interfere with sleep No cure, and treatment is individualized 68 Regina is a 46 y.o. woman with ulcerative colitis. You expect her stools to look like: 1. 2. 3. 4. Watery and frothy. Bloody and mucous. Firm and well-formed. Alternating constipation and diarrhea. 69 Diverticula Diverticular Disease of the Colon Diverticulosis Herniations of mucosa through the muscle layers of the colon wall, especially the sigmoid colon Asymptomatic diverticular disease Diverticulitis The inflammatory stage of diverticulosis 70 Diverticular Disease of the Colon (Cont.) Diverticula can occur anywhere in the gastrointestinal tract, particularly at weak points in the colon wall Complicated diverticulitis includes abscess, fistula, obstruction, bleeding, or perforation Symptoms of uncomplicated diverticular disease may be vague or absent 71 Donald is a 61 y.o. man with diverticulitis. Diverticulitis is characterized by: 1. Periodic rectal hemorrhage. 2. Hypertension and tachycardia. 3. Vomiting and elevated temperature. 4. Crampy and lower left quadrant pain and low-grade fever. Pathophysiology Overview Life-threatening, acute inflammation and infection of visceral/parietal peritoneum and endothelial lining of abdominal cavity Often caused by contamination of the peritoneal cavity by bacteria or chemicals Peritonitis Peritonitis: Etiology Common bacteria Chemical – leakage of bile, pancreatic enzymes, gastric acid Peritonitis: Incidence and Prevalence Dominant cause of death from surgical infections Peritonitis: Assessmen t: Recognize Cues History Pain, type, and location Fever Physical Assessment/Signs & Symptoms Movement may be guarded Abdominal pain, tenderness, and distention Psychosocial Assessment Peritonitis: Assessmen t: Recognize Cues Laboratory assessment WBC Blood cultures BUN, creatinine Hemoglobin, hematocrit ABG, oxygen saturation Imaging assessment Abdominal x-rays or ultrasound 77 Inflammation of the vermiform appendix Possible causes: Appendicitis Gastric or periumbilical pain Obstruction, foreign bodies, infection Rebound tenderness to RLQ Perforation, peritonitis, and abscess formation are the most serious complications 78 Portal hypertension Liver Disorders Abnormally high blood pressure in the portal venous system caused by resistance to portal blood flow Intrahepatic Posthepatic 79 Portal hypertension (Cont.) Liver Disorders (Cont.) Varices Lower esophagus Stomach Abdominal wall Rectum Splenomegaly Hepatopulmonary syndrome Portopulmonary syndrome Vomiting of blood from bleeding esophageal varices is the most common clinical manifestation 8 0 Varices Ascites Accumulation of fluid in the peritoneal cavity Most common cause is cirrhosis Development associated with Liver Disorders Portal hypertension Decreased synthesis of albumin by the liver Splanchnic vasodilation Renal sodium and water retention 25% mortality in 1 year if associated with cirrhosis Causes abdominal distention and increased abdominal girth and weight gain Paracentesis 81 82 Case Study: Ascites M.M. is a 55 yr old female admitted for new onset ascites and lower extremity edema. One month ago she was hospitalized for a UGI bleed and diagnosed with grade 1 esophageal varices. Patient reports being forgetful, not sleeping well, and is drowsy and fatigued during day. No abdominal pain. She has a 10 year history of diabetes and hypertension. She drank alcohol moderately heavy up to 20 years ago and now drinks less than 3 drinks per week. What are the potential causes of her ascites? Further assessment? Nursing diagnoses? 83 Liver Disorders Hepatic encephalopathy A neurologic syndrome of impaired behavioral, cognitive, and motor function The condition develops rapidly during fulminant hepatitis or slowly during course of liver disease Cells in the nervous system are vulnerable to neurotoxins absorbed from the GI tract that, because of liver dysfunction, circulate to the brain 84 Hepatic encephalopathy (Cont.) Liver Disorders (Cont.) Early symptoms Subtle changes in personality, memory loss, irritability, disinhibition, lethargy, and sleep disturbances Later symptoms Confusion, disorientation to time and space, flapping tremor of the hands (asterixis), slow speech, bradykinesia, stupor, convulsions, and coma 85 Hepatic encephalopathy develops when the blood level of which substance increases? 1. 2. 3. 4. Ammonia Amylase Calcium Potassium 86 Liver Disorders (Cont.) Jaundice (icterus) Caused by hyperbilirubinemia Obstructive jaundice Extrahepatic obstruction Intrahepatic obstruction Hemolytic jaundice Prehepatic jaundice Excessive hemolysis of red blood cells Characterized by dark urine, yellow discoloration of sclera and skin, and light-colored stools 87 Acute Liver Failure Rare clinical syndrome resulting in severe impairment or necrosis of liver cells without preexisting liver disease or cirrhosis Acetaminophen overdose is leading cause in the United States 88 Irreversible inflammatory, fibrotic liver disease Biliary channels become obstructed and cause portal hypertension Severity and rate of progression depend on the cause Many causes Cirrhosis 89 Alcoholic Liver Disease Related to toxic effects of alcohol and coexisting liver disease Alcoholic fatty liver Alcoholic steatohepatitis Alcoholic cirrhosis Anorexia, nausea, jaundice, and edema develop with advanced fatty infiltration or the onset of alcoholic steatohepatitis 90 Nonalcoholic Fatty Liver Disease and Nonalcoholic Steatohepatiti s Nonalcoholic fatty liver disease (NAFLD) Infiltration of hepatocytes with fat occurring in the absence of alcohol intake May progress to nonalcoholic steatohepatitis, which may progress to cirrhosis and endstage liver disease 91 The nurse is caring for a male client with cirrhosis. Which assessment findings indicate that the client has deficient vitamin K absorption caused by this hepatic disease? A. Dyspnea and fatigue B. Ascites and orthopnea C. Purpura and petechiae D. Gynecomastia and testicular atrophy 92 Viral Hepatitis Systemic viral disease that primarily affects the liver 5 types (A, B, C, D, and E) Can cause acute, icteric illness Spectrum of manifestations ranges from absence of symptoms to fulminating hepatitis, with rapid onset of liver failure and coma Hepatitis: Etiology (1 of 2) HAV Commonly found in shellfish caught in contaminated water Food handlers HBV Unprotected sexual intercourse with infected partner Sharing needles, syringes, druginjection equipment Sharing razors, toothbrushes with infected individual Accidental needlesticks or injuries from sharps Blood transfusions (before 1992) Hemodialysis Direct contact with blood or open sores of infected individual Birth (mother to baby) Hepatitis: Etiology (2 of 2) HCV Illicit IV drug needle sharing (highest incidence) Blood, blood products, or organ transplants received before 1992 Baby boomers (those adults born between 1945 and 1965) Needlestick injury with HCV-contaminated blood (health care workers at high risk) Hemodialysis Health care workers People who are incarcerated (prisoners0 Sharing of drug paraphernalia HDV Defective RNA virus that needs helper function of HBV Parenteral routes, especially in those who use IV drugs HEV Waterborne infection associated with epidemics in some countries Hepatitis: Incidence and Prevalence HAV and HBV are declining due to vaccination. HBC and HBC are still concerning. HCV most common bloodborne infection in U.S. no vaccine is available. Hepatitis: Health Promotion and Maintenance Vaccines for HAV and HBV Healthcare workers – standard precautions; needleless systems HAV-specific recommendations Proper handwashing (especially after handling shellfish) Avoid contaminated food or water. 97 Viral Hepatitis (Cont.) Phases Incubation Prodromal Icteric Recovery Chronic active hepatitis 98 Case Study: Viral Hepatitis A 57-year-old male was diagnosed with Hepatitis C on a preemployment physical. He has been good health, has no major medical problems, and he does not take any prescription medications. He is moderately overweight (BMI of 33), drinks alcohol (occasionally to excess), and smokes. The patient admits to the physician that as a young man he had experimented with IV drugs for a brief period of time, but has not used any illicit substances for over 35 years. Laboratory tests reveal moderate elevation of liver enzymes A test for hepatitis C antibodies is positive and hepatitis C RNA is detected. A scan of his liver reveals a mild level of fibrosis but no cirrhosis. Risk factors for hepatitis C? Nursing diagnoses? 99 A female patient who has just been diagnosed with hepatitis A asks, “How could I have gotten this disease?” What is the nurse’s best response? A. “You may have eaten contaminated restaurant food.” B. “You could have gotten it by using I.V. drugs.” C. “You must have received an infected blood transfusion.” D. “You probably got it by engaging in unprotected sex.” 100 Which of the following factors can cause hepatitis C? Check all that apply A. Contact with infected blood B. Blood transfusions with infected blood C. Eating contaminated shellfish D. Sexual contact with an infected person Copyright © 2017, Elsevier Inc. All rights reserved. 101 Disorders of the Gallbladder Obstruction or inflammation (cholecystitis) is the most common cause of gallbladder problems Cholelithiasis—gallstone formation Risks Obesity Middle age Female Oral contraceptive use Rapid weight loss Native American ancestry Gallbladder, pancreas, or ileal disease 102 Gallstones Formed from impaired metabolism of cholesterol, bilirubin, and bile acids Type depends on chemical composition Disorders of the Gallbladder (Cont.) Cholesterol Pigmented brown Formed from bile that is supersaturated with cholesterol produced by the liver Formed from calcium bilirubinate and fatty acid soaps that bind with calcium Black Composed of calcium bilirubinate with mucin glycoproteins Associated with chronic liver disease and hemolytic disease 103 Disorders of the Gallbladder (Cont.) Gallstones (Cont.) Often asymptomatic or vague Epigastric and right hypochondrium pain Intolerance to fatty foods 104 Disorders of the Gallbladder Cholecystitis Almost always caused by a gallstone lodged in the cystic duct Pain is similar to that caused by gallstones Fever, leukocytosis, rebound tenderness, and abdominal muscle guarding are common findings 105 Case Study: Cholecystitis A 42 year-old woman presents to the ER complaining of abdominal pain, nausea and vomiting. She notes she has had prior similar episodes which resolved spontaneously however the pain today has persisted for five hours and is much more severe. She appears uncomfortable and is clutching her abdomen. The pain is located in the right upper quadrant of her abdomen and radiates to her upper back. She describes the pain as dull and cramping. The patient's vital signs are as follows: BP 148/96, P108, R18, T99.9. She has a history of hypertension and is overweight. Further assessment data? Nursing diagnoses? 106 Disorders of the Pancreas Pancreatitis Inflammation of the pancreas Develops because of obstruction to the outflow of pancreatic digestive enzymes caused by bile and pancreatic duct obstruction Disorders of the Pancreas (Cont.) Acute pancreatitis Usually mild and resolves spontaneously May result from direct cellular injury from alcohol, drugs, or viral infection Cardinal manifestation is epigastric or midabdominal constant pain 107 Chronic pancreatitis Process of progressive fibrotic destruction of the pancreas Related to chronic alcohol abuse Continuous or intermittent abdominal pain and weight loss are common Risk factor for pancreatic cancer 108 Cancer of the Gastrointestin al Tract Esophagus Squamous cell carcinoma Adenocarcinoma Risk factors include chronic alcohol use combined with smoking or chewing tobacco, hot and irritant (alcohol) drinks, food containing nitrosamines, and achalasia Frequent symptoms are chest pain and dysphagia 109 Cancer of the Gastrointestin al Tract (Cont.) Stomach Associated with atrophic gastritis and Helicobacter pylori Sporadic and associated with consumption of heavily salted and preserved foods, low intake of fruits and vegetables, and use of tobacco and alcohol Vague symptoms early such as loss of appetite, malaise, and indigestion Later symptoms of unexplained weight loss, upper abdominal pain, vomiting, change in bowel habits, and anemia 110 Colon and rectum Most are sporadic or associated with a family history of colorectal cancer Caused by multiple gene alterations and environmental interactions Cancer of the Gastrointestin al Tract (Cont.) Familial adenomatous polyposis Hereditary nonpolyposis Colorectal polyps Neoplastic polyps Symptoms depend on the location, size, and shape of the lesion and are silent in the early stages 111 Colon Cancer 112 Cancer of the Accessory Organs of Digestion Liver Usually caused by metastatic spread from a primary site elsewhere in the body Hepatocellular carcinoma Usually asymptomatic Cholangiocellular carcinoma Commonly presents insidiously as pain, loss of appetite, weight loss, and gradual onset of jaundice 113 Cancer of the Accessory Organs of Digestion (Cont.) Gallbladder Usually caused by metastasis Chronic inflammation may trigger dysplasia and progress to metaplasia Early stages usually asymptomatic Usually caught in late stages 114 Cancer of the Accessory Organs of Digestion (Cont.) Pancreas Ductal adenocarcinomas Pancreatic tumors from metaplastic exocrine cells in the ducts Chronic pancreatitis and inflammatory cytokines support tumor growth When symptoms occur, there usually has been a malignant transformation
