Digestive System Overview PDF

CEBU DOCTORS’ UNIVERSITY COLLEGE OF NURSING BATCH 2024 Concept of Metabolism and Alterations in Digestion and Absorption Ms. Ph...

CEBU DOCTORS’ UNIVERSITY COLLEGE OF NURSING BATCH 2024 Concept of Metabolism and Alterations in Digestion and Absorption Ms. Phoebe Kates T. Mangarin Digestive System Overview Intrinsic Factor Major Functions: Maltase Digestion Sucrase Intestinal Absorption Lactase Mucosa Elimination Aminopeptidase Dipeptidase Major Digestive Enzymes and Secretions Trypsin Pancreas Amylase ENZYME SOURCE ENZYME/SECRETION Lipase Mouth Ptyalin or Salivary Amylase (Salivary Glands) Liver and Bile Gallbladder Stomach Hydrochloric Acid (Gastric Mucosa) Pepsin Peptic Ulcer Disease A peptic ulcer is an excavation that forms in the mucosal wall of the stomach (in the pylorus), in the duodenum, or in the esophagus. *PUD are more likely to occur in the duodenum than in the stomach *The use of NSAIDs (e.g., Ibuprofen, aspirin) represents a major risk factor for peptic ulcers. NSAIDs and H. Pylori impair the protective gastric mucosa, and the failure of the GI tract to repair the protective gastric mucosa, and the failure of the GI tract to repair the mucosa may result in ulcerations. *2 specific types of ulcers: 1. Curling Ulcers - frequently observed after extensive burn injuries and often involves the antrum of the stomach or the duodenum. 2. Cushing Ulcers - common in patients with a traumatic head Injury, stroke, brain tumor or following Intracranial surgery. Thought to be caused by intracranial pressure, which results in overstimulation of the vagal verve and is increased secretion in overstimulation of the vagal nerve and an Increased secretion of gastric acid. Pathophysiology 1  CEBU DOCTORS’ UNIVERSITY COLLEGE OF NURSING BATCH 2024 Concept of Metabolism and Alterations in Digestion and Absorption Ms. Phoebe Kates T. Mangarin Difference between Gastric Ulcer and Duodenal Ulcer GASTRIC ULCER DUODENAL ULCER AGE > 50 years old 30 to 60 years old SEX Women Men INCIDENCE 20% 80% HCl Normal or decreased More than normal PAIN Occurrence 2-3 hours after meals Shortly after meals/15-30 minutes after meals Common: night time Location Epigastric (mid/left) Midepigastrium Description Burning/gnawing Burning/gnawing Relieved by Vomiting Food/antacids Effect Weight Loss Weight gain/maintain weight Diagnostic Tests C. Highly Selective Vagotomy (parietal cell gastric Physical Examination vagotomy): denervates acid-secreting parietal cells Endoscopy but preserves vagal innervation to the gastric Complete Blood Cuunt antrum and pylorus. Stool Exam Pharmacologic Management Combination of antibiotics, proton pump inhibitors, and bismuth salts Recommended Therapy: 10 to 14 days Triple therapy (2 antibiotics + 1 proton pump inhibitor) Quadruple therapy (2 antibiotics + proton pump inhibitor and bismuth salts) Best Prefix/Suffix Actions Taken ANTACIDS After Ca, Al-OH Neutralize HCl Pyloroplasty meals H2 BLOCKERS Longitudinal incision is made into the pylorus and -tidine Decrease/Reduce HCl Once transversely sutured closed to enlarge the outlet and relax (Ranitidine) production (bedtime) the muscle; usually accompanies truncal and selective PROTON PUMP INHIBITORS (PPIs) vagotomies. -prazole Before *Transecting nerves that stimulate acid secretion and Stops HCl production opening the pylorus (Omeprazole) meals MUCOSAL PROTECTIVE Coats ulcer Before Sucralfate Barrier: mucus meals Surgical Management Vagotomy Severing of the vagus nerve. Decreases gastric acid by diminishing cholinergic stimulation to the parietal cells, making them less responsive to gastrin. A. Truncal Vagotomy: severs the right and left vagus nerves as they enter the stomach at the distal part of the esophagus. B. Selective Vagotomy: severs vagal innervation to the stomach but maintains innervation to the rest of the abdominal organs. 2  CEBU DOCTORS’ UNIVERSITY COLLEGE OF NURSING BATCH 2024 Concept of Metabolism and Alterations in Digestion and Absorption Ms. Phoebe Kates T. Mangarin Antrectomy Rigid or board-like abdomen → peritonitis A. Billroth I (gastroduodenostomy): removal of the Ecchymosis in the flank or around the umbilicus → lower portion of the antrum of the stomach (which severe pancreatitis contains the cells that secrete gastrin) as well as a Nausea and vomiting → Risk for Fluid Volume small portion of the duodenum and pylorus. The Deficit remaining segment is anastomosed to the Fever duodenum. Jaundice B. Billroth II (gastrojejunostomy): removal of the Mental confusion lower portion (antrum) of stomach with Agitation anastomosis to jejunum. Hypotension Tachycardia Cyanosis Cold, clammy skin Diagnostic Tests Serum amylase: ↑ - (+) leakage → injured pancreas Serum lipase (more reliable) Urinary amylase X-ray studies Ultrasound studies Nursing Management Contrast-enhanced CT scans Relieving pain MRI Reducing stress and anxiety Hematocrit and hemoglobin levels Maintaining optimal nutritional status Endoscopic Retrograde Cholangiopancreatography Monitor complications (rarely used) *Smoking cessation - smoking decreases the secretion of bicarbonate from the pancreas into the duodenum, Pharmacologic Management: resulting in increased acidity of the duodenum. Continued H2 antagonists: to decrease pancreatic activity smoking is also associated with delayed healing of peptic PPIs: for patients who do not tolerate H2 ulcers. antagonists or for whom this therapy is ineffective Pancreatitis (Karch, 2012) Pancreatitis is the inflammation of the pancreas. Analgesia “autodigestion of the pancreas” Medical Management Pathophysiology Goal: relieving symptoms and preventing or treating complications. Parenteral nutrition Enteral feedings Nasogastric suction: to relieve nausea and vomiting and to decrease painful abdominal distention and paralytic ileus Nursing Management Relieving pain and discomfort Narcotics: morphine NPO: to prevent stimulation of pancreatic enzymes Total Parenteral Nutrition (TPN) Frequent oral hygiene: to decrease discomfort from the NGT and relieves dryness of the mouth Signs and Symptoms Bed rest: knee-to-chest (fetal position) Pain Improving breathing pattern Midepigastrium o Semi-fowler’s position Acute in onset o Coughing and deep breathing techniques Occurring 24 to 48 hours after a very heavy o Use of incentive spirometry meal/alcohol ingestion o Diffuse/difficult to localize Monitor complications Abdominal guarding 3  CEBU DOCTORS’ UNIVERSITY COLLEGE OF NURSING BATCH 2024 Concept of Metabolism and Alterations in Digestion and Absorption Ms. Phoebe Kates T. Mangarin Cholelithiasis, Choledocholithiasis, & Cholecystitis Cholelithiasis Choledocholithiasis Cholecystitis Presence of gallstones in the Presence of gallstones in the common Inflammation of the gallbladder. gallbladder. bile duct. Pathophysiology 2 Major Types of Gallstones Cholesterol Stones Pigment Stones There is decreased bile acid synthesis and increased cholesterol synthesis in the liver, resulting in bile Composed predominantly of pigment and supersaturated with cholesterol, which precipitates out of cholesterol. the bile to form stones (Hammer & McPhee, 2019). Forms when unconjugated pigments in the bile precipitate to form stones. Cannot be dissolved and must be removed surgically 4  CEBU DOCTORS’ UNIVERSITY COLLEGE OF NURSING BATCH 2024 Concept of Metabolism and Alterations in Digestion and Absorption Ms. Phoebe Kates T. Mangarin 2 Major Types of Cholecystitis Nutritional and Supportive Therapy Calculous Cholecystitis The diet immediately after an episode is usually low-fat liquids. More than 90% of cases These can include powdered supplements high in Results when there is presence of gallstones which protein and carbohydrate stirred into skim milk. obstructs bile outflow. Bile remaining in the gallbladder initiates a chemical reaction; autolysis Cooked fruits, rice or tapioca, lean meats, mashed and edema occur; and the blood vessels in the potatoes, nongas-forming vegetables, bread, gallbladder are compressed, compromising its coffee, or tea. vascular supply. ❌eggs, cream, pork, fried foods, cheese, rich dressings, gas-forming vegetables, and alcohol Acalculous Cholecystitis GAS PRODUCING FRUITS AND VEGETABLES Inflammation in the absence of gallstones Cauliflower Occurs after major surgical procedures, orthopedic Brussels Sprouts procedures, severe trauma, or burns. Cabbage Caused by alterations in fluids and electrolytes and Apples alterations in regional blood flow in the visceral Onions circulation. Cherries Signs and Symptoms Beans Pain: Peaches o Site: RUQ Raisins o Radiation: right shoulder/scapula ANTI BLOAT FOODS o Aggravated: ↑ fat intake Almonds Fever Apples (+) Murphy’s sign Avocadoes Nausea and vomiting Bilberries Palpable abdominal mass may be present Bananas Jaundice (d/t obstruction of the CBD) Whole melons Urine: tea-colored Carrots Steatorrhea (fat in stool): gray/clay- Broccoli colored/acholic stool Celery Diagnostic Tests Whole citrus Abdominal X-ray Garlic Ultrasonography Cranberries Cholescintigraphy Dandelions Oral Cholecystography Ginger Endoscopic Retrograde Cholangiopancreatography Herbal Teas Percutaneous Transhepatic Cholangiography Parsley (rarely used) Spinach Blood tests Flaxseed Pharmacologic Management Cabbage Ursodeoxycholic acid (UDCA) and Non-Surgical Management chenodeoxycholic acid (chenodiol or CDCA): to Extracorporeal shock wave lithotripsy (ESWL): used dissolve small, radiolucent gallstones composed for nonsurgical fragmentation of gallstones. It uses primarily of cholesterol (Goldman & Shafer, 2019). repeated shock waves directed at the gallstones in Medical Management the gallbladder or CBD to fragment the stones. Objectives: 1. To reduce the incidence of acute episodes of gallbladder pain and cholecystitis by supportive and dietary management and 2. If possible, to remove the cause of cholecystitis by pharmacologic therapy, endoscopic procedures, or surgical intervention. 5  CEBU DOCTORS’ UNIVERSITY COLLEGE OF NURSING BATCH 2024 Concept of Metabolism and Alterations in Digestion and Absorption Ms. Phoebe Kates T. Mangarin Surgical Management Signs and Symptoms Cholecystectomy: the gallbladder is removed Pain through an abdominal incision (usually right o Site: RLQ → Mcburney’s point subcostal) after the cystic duct and artery are Rovsing’s sign → palpate LLQ → (+) RLQ pain ligated. Psoas’ sign Choledochostomy: formation of a temporary Obturator sign opening through the abdominal wall into the Dunphy’s sign common bile duct, usually to remove stones. Blumberg’s sign a.k.a rebound tenderness Cholecystostomy: is a minimally invasive procedure o Palpate the RLQ → (+) pain upon removal used to drain the fluid buildup in the gallbladder. of pressure Nursing Management N/V + diarrhea Relieving pain Fever (low-grade) Maintaining skin integrity and promoting biliary drainage Improving nutritional status Monitor complications Appendicitis An inflammation of the inner lining of the vermiform appendix that spreads to its other parts. Pathophysiology Diagnostic Tests WBC Count: >10,500/mm3 C-reactive protein levels: elevated within the first 12 hours of symptoms CT scan Abdominal UTZ Pregnancy test (women of childbearing age) Urinalysis 6  CEBU DOCTORS’ UNIVERSITY COLLEGE OF NURSING BATCH 2024 Concept of Metabolism and Alterations in Digestion and Absorption Ms. Phoebe Kates T. Mangarin Pharmacologic Management 1. Pain relief medications (opioids, nonsteroidal anti-inflammatory drugs (NSAIDs), or acetaminophen) 2. Antibiotics A whole menagerie of bacteria, including Escherichia, Pseudomonas, Peptostreptococcus, Bilophila, and Bacteroides, cause appendicitis. Therefore, a variety of wide-spectrum antibiotics can fight off the infection, including: o Penicillin-type drugs with a beta-lactamase inhibitor: Zosyn (piperacillin and tazobactam), Unasyn (ampicillin-sulbactam) o Cephalosporins: Rocephin (ceftriaxone), Cefotan (cefotetan) o Carbapenems: Merrem (meropenem), Invanz (ertapenem) o Aminoglycosides: Gentak (gentamicin) o Nitroimidazoles: Flagyl (metronidazole) o Lincomycins: Cleocin (clindamycin) Best Medications for Appendicitis Administration Drug Name Drug Class Standard Dosage Common Side Effects Route Zosyn 50 mL of 3-0.375 grams Diarrhea, headache, constipation Antibiotic Oral (piperacillintozabactam) every 6 hours Rocephin 4-8. 350 mg injections in 2 Rash, nausea, diarrhea Antibiotic Injection (ceftriaxone) daily doses Flagyl Dose depends on weight Nausea, headache, loss of appetite Antibiotic Oral (metronidazole) Ultram 1, 50 mg tablets twice per Dizziness, nausea, constipation Opioid Oral (tramadol) day 2-3, 50 mg tablets divided Abdominal pain, constipation, Diclofenac NSAID Oral into 2 daily doses diarrhea The standard dosages above are from the United States Food and Drug Administration (FDA). Your healthcare provider will determine the right dosage for you based on your medical condition, response to treatment, age and weight. Other possible side effects exist. Surgical Management Gastritis Appendectomy: surgical removal of the appendix An Inflammation of the gastric or stomach mucosa gold-standard treatment for acute appendicitis *May be acute or chronic Nursing Management Pathophysiology Goals: relieving pain, preventing fluid volume deficit, reducing anxiety, preventing or treating surgical site infection, preventing atelectasis, maintaining skin integrity, and attaining optimal nutrition. 1. IV infusion to replace fluid loss and promote adequate renal function 2. Administer antibiotics and analgesics as prescribed by the physician. ❌enema and laxatives 3. Post-operative position: High-Fowler’s position → reduces tension on the incision and abdominal organs, helping to reduce pain. It also promotes thoracic expansion, diminishing the work of breathing, and decreasing the likelihood of atelectasis. 7  CEBU DOCTORS’ UNIVERSITY COLLEGE OF NURSING BATCH 2024 Concept of Metabolism and Alterations in Digestion and Absorption Ms. Phoebe Kates T. Mangarin Signs and Symptoms Diagnostic Tests Acute Gastritis Endoscopy Epigastric pain or discomfort Complete blood count (CBC) Dyspepsia Pharmacologic Management Anorexia Antacids Hiccups Histamine-2 receptor antagonists (H2 blockers) N/V PPIs Erosive gastritis → melena or hematochezia Medical Management Chronic Gastritis IV fluids Fatigue Surgical Management Pyrosis (“heartburn”) after eating Gastric resection or a gastrojejunostomy Belching (anastomosis of jejunum to stomach to detour Sour taste in the mouth around the pylorus) Halitosis Nursing Management Early satiety Reducing anxiety Anorexia Promoting optimal nutrition N/V Gastritis Promoting fluid balance Relieving pain Diverticular Disease Diverticulum Diverticulosis Diverticulitis A saclike herniation of the lining of the The presence of multiple diverticula Inflammation of one or more bowel that extends through a defect in without inflammation or symptoms. diverticula. the muscle layer. Pathophysiology Diagnostic Tests Colonoscopy Abdominal CT Scan with contrast agent Blood analysis Abdominal X-rays Modified Hinchey Classification: Staging of Acute, Complicated Diverticulitis STAGE DESCRIPTION CATEGORY 0 Mild diverticulitis or diverticula with colonic thickening on CT Uncomplicated Ia Colonic reaction with inflammatory reaction in the pericolic fate Uncomplicated Ib Localized pericolic or mesenteric abscess Complicated II Intra-abdominal, pelvic, or retroperitoneal abscess Complicated III Perforated diverticulitis causing generalized purulent peritonitis Complicated IV Rupture of diverticula into the peritoneal cavity with generalized fecal peritonitis Complicated 8  CEBU DOCTORS’ UNIVERSITY COLLEGE OF NURSING BATCH 2024 Concept of Metabolism and Alterations in Digestion and Absorption Ms. Phoebe Kates T. Mangarin Pharmacologic Management The second operation is performed 2-8 weeks later to resect the diseased bowel and perform a primary Empiric therapy requires broad-spectrum antibiotics anastomosis. effective against known enteric pathogens. For A third operation, performed 2-4 weeks after the complicated cases of diverticulitis in hospitalized patients, second operation, closes the stoma. carbapenems are the most effective empiric therapy because of increasing bacterial resistance to other Medical Management regimens. Clear liquid diet is consumed until the inflammation Potential regimens include the following: subsides; then a high-fiber, low-fat diet is recommended. Ciprofloxacin plus metronidazole Nursing Management Trimethoprim-sulfamethoxazole plus Promote bowel rest metronidazole NPO: during acute stage (pain) Amoxicillin-clavulanate Bed rest Moxifloxacin (use in patients intolerant of both IVF metronidazole and beta lactam agents) ❌foods with seeds Antispasmodics (propantheline, dicyclomine) Increase fluid intake of 2L/day Surgical Management A two-stage surgical approach is generally the most common procedure performed for the emergency treatment of acute diverticulitis. Note the following: The preferred surgical approach in patients with fecal peritonitis and in most cases of purulent peritonitis is the traditional Hartmann procedure. It involves resection of the diseased segment of bowel, an end-colostomy, and closure of the rectal stump. Typically, 3 months later, a second procedure may be performed in which the colostomy is reversed and the intestinal continuity is reestablished with the rectal stump; however, this second operation can be technically difficult and is not performed in many patients. An alternative to the Hartmann procedure involves resection of the diseased colon, primary anastomosis (with or without intraoperative colonic lavage), and creation of a proximal diverting stoma, either via colostomy or ileostomy. The second procedure in this process would be to close the stoma. This approach is primarily used when there are relative contraindications to the primary anastomosis but no purulent or feculent peritonitis, and there is nonedematous bowel. Its advantage lies in avoiding the technically difficult second stage used in the Hartmann procedure. The classic three-stage surgical approach is rarely indicated at present because of its high associated morbidity and mortality. This procedure is considered only in critical situations in which resection cannot safely be performed. Consider the following: In the three-stage approach, the initial operation is simply drainage of the diseased segment and creation of a proximal diversion colostomy, without resection. 9