The Gastrointestinal System and Its Disorders PDF

Republic of the Philippines Bulacan State University City of Malolos, Bulacan COLLEGE OF NURSING Medical-Surgical Nursing...

Republic of the Philippines Bulacan State University City of Malolos, Bulacan COLLEGE OF NURSING Medical-Surgical Nursing THE DIGESTIVE SYSTEM I. ANATOMY OF THE DIGESTIVE SYSTEM The organs of the digestive system can be separated into two main groups: those forming the alimentary canal and the accessory digestive organs. The alimentary canal performs the whole menu of digestive functions (ingests, digests, absorbs, and defecates). The accessory organs (teeth, tongue, and several large digestive glands) assist the process of digestive breakdown in various ways. A. Organs of the Alimentary Canal The alimentary canal, also called the gastrointestinal (GI) tract, is a continuous, coiled, hollow, muscular tube that winds through the ventral body cavity and is open at both ends. Its organs are the mouth, pharynx, esophagus, stomach, small intestine, and large intestine. 1. Mouth  A mucous membrane- lined cavity where food first enter; also called oral cavity  Hard palate – forms the anterior roof of the mouth  Soft palate – forms the posterior roof of the mouth  Uvula – a fleshy fingerlike projection of the soft palate, which extends downward from its posterior edge  Tongue – occupies floor of the mouth  Lingual frenulum – secures the tongue to the floor of the mouth and limits its posterior movement 2. Pharynx 3. Esophagus  Also called gullet, runs from the pharynx through the diaphragm to the stomach; about 25cm (10in) long. Page 1 of 29 4. Stomach  A C-shaped organ on the left side of the abdominal cavity, nearly hidden by the liver and diaphragm  It has different regions: a. Cardiac region – surrounds the cardiac sphincter, through which food enters the stomach from the esophagus b. Fundus – the expanded part of the stomach lateral to the cardiac region c. Body – the midportion d. Pylorus – terminal part of the stomach; it contains the pyloric sphincter or valve  Parietal cells – produce corrosive hydrochloric acid, which makes the stomach contents acidic and activates the enzyme  Chief cells – produce protein-digesting enzymes, mostly pepsinogens  Chyme – heavy cream resemblance of food after being processed by the stomach 5. Small intestine  The body’s major digestive organ  The longest section of the alimentary tube in a living person  3 subdivisions: a. Duodenum b. Jejunum c. Ileum  Pancreatic duct – port where enzymes produced by the intestinal cells and pancreas travel to complete the chemical breakdown of foods in the intestine  Bile duct – duct where bile, produced by the liver, travels  Nearly all food absorption occurs in the small intestine 6. Large intestine  Larger in diameter than the small intestine but shorter in length  It extends from the ileocecal valve to the anus  Its major functions are to dry out the indigestible food residues from the body as feces  Subdivisions: a. Cecum b. Appendix c. Colon d. Rectum e. Anal canal  Regions: a. Ascending colon b. Transverse colon c. Descending colon d. Sigmoid colon  Goblet cells – produce mucus that act to ease passage of feces to the anus B. Accessory Digestive Organs 1. Salivary glands  3 pairs: a. Parotid glands b. Submandibular glands c. Sublingual glands Page 2 of 29   Saliva – product of the salivary glands 2. Teeth  For mastication or chewing of food  Deciduous teeth – baby or milk teeth; begin to erupt around 6mos in a baby and has a full set (20 teeth) at the age of 2years.  Permanent teeth – usually erupted by the end of adolescence  Wisdom teeth – the third molars; emerge later between the ages of 17 and 25  Classification according to shape and function: a. Incisors – chisel-shaped; for cutting b. Canines – fanglike; for tearing or piercing c. Premolars – broad crowns; for grinding d. Molars - broad crowns; for grinding  Two major regions: a. Crown b. Root 3. Pancreas  Soft, pink, triangular gland that extends across the abdomen from the spleen to the duodenum  Pancreatic enzymes – secreted into the duodenum which neutralizes the acidic chime coming in from the stomach 4. Liver and Gallbladder  Liver is the largest gland in the body  Located under the diaphragm, more to the right side of the body  Bile – produced by the liver that leaves through the common hepatic duct and enters the duodenum through the bile duct; yellow-to-green secretion that emulsify fats by physically breaking large fat globules into smaller ones  Gallbladder is a small, thin-walled green sac that snuggles in a shallow fossa in the inferior surface of the liver; bile storage area C. FUNCTION OF THE DIGESTIVE SYSTEM C.1 Gastrointestinal Processes and Controls 1. Ingestion 2. Propulsion  Peristalsis – involuntary and involves alternating waves of contraction and relaxation of the muscles in the organ wall. The net effect is to squeeze the food along the tract 3. Food breakdown: mechanical digestion 4. Food breakdown: chemical digestion Enzymes Source Digestive Action Action of enzymes that digest carbohydrates Ptyalin (salivary amylase) Salivary glands starchdextrin, maltose, glucose Amylase Pancreas and intestinal mucosa starchdextrin, maltose, glucose Maltase Intestinal mucosa maltoseglucose Sucrose Intestinal mucosa sucroseglucose, fructose Lactase Intestinal mucosa lactoseglucose, galactose Action of enzymes that digest proteins Pepsin Gastric mucosa Proteinpolypeptides Page 3 of 29 Trypsin Pancreas Proteins&polypeptidespolypeptides, dipeptides, amino acids Aminopeptidase Intestinal mucosa polypeptides dipeptides, amino acids Dipeptidase Intestinal mucosa dipeptidesamino acids Hydrochloric acid (HCL) Gastric mucosa proteinpolypeptides, amino acids Action of enzymes that digest fat Pharyngeal lipase Pharynx mucosa triglyceridesfatty acids, diglycerides, monoglycerides Steapsin Gastric mucosa triglyceridesfatty acids, diglycerides, monoglycerides Pancreatic lipase Pancreas triglyceridesfatty acids, diglycerides, monoglycerides Bile Liver and gallbladder fat emulsification 5. Absorption 6. Defecation D. NUTRITION AND METABOLISM Most foods are used as metabolic fuels. That is they are oxidized and transformed into ATP, the chemical energy form needed by body cells to drive their many activities. The energy value of foods is measured in units called kilocalories (kcal) or “large calories” (C). 1. Nutrition  Nutrient – a substance in food that is used by the body to promote normal growth, maintenance, and repair.  Dietary sources of the major nutrients: a. Carbohydrates b. Lipids c. Proteins d. Vitamins e. Minerals 2. Metabolism  A broad term referring to all chemical reactions that are necessary to maintain life. It involves catabolism, in which substances are broken down to simpler substances, and anabolism, in which larger molecules or structures are built from smaller ones. 3. Body Energy Balance  “Energy cannot be created nor destroyed – it can only be converted from one form to another”  Energy intake – the energy liberated during food oxidation  Energy output – the energy we immediately lose as heat plus that used to do work plus energy that is stored in the form of fat or glycogen. Energy intake = Total energy output (heat + work + energy storage) 4. Metabolic Rate and Body Heat Production  Basal metabolic rate – the amount of heat produced by the body per unit of time when it is under basal conditions – that is, at rest  Total metabolic rate – refers to the total amount of kilocalories the body must consume to fuel all ongoing activities. Page 4 of 29 5. Body Temperature Regulation  Heat-Promoting Mechanisms - Vasoconstriction, shivering  Heat Loss Mechanism - Radiation, evaporation Page 5 of 29  CARE OF THE CLIENTS WITH GASTROINTESTINAL DISORDERS I. Assessment of the Gastrointestinal Function A. Health History and Clinical Manifestations 1. Pain a. Characteristics b. Duration c. Pattern d. Frequency e. Location f. Distribution 2. Dyspepsia (upper abdominal discomfort or GI distress) 3. Intestinal gas 4. Nausea and vomiting 5. Change in bowel habits and stool characteristics  Diarrhea  Constipation  Tarry-black stool  Bright or dark red stool  Light-gray or clay-colored stool  Stool with mucus threads or pus B. Physical Assessment 1. Inspection, Auscultation, Palpation and Percussion (IAPP) 2. Proper positioning – dorsal recumbent 3. Four Quadrants (RUQ, RLQ, LUQ, LLQ) 4. Nine Regions: i. Epigastric region ii. Umbilical region iii. Hypogastric or suprapubic region iv. Right hypochondriac region v. Left hypochondriac region vi. Right lumbar region vii. Left lumbar region viii. Right inguinal region ix. Left inguinal region Page 6 of 29 C. Diagnostic Evaluation 1. Hematologic Tests a. CBC, PT/PTT, triglycerides b. Carcinoembryonic Antigen (CEA) - A protein that is not normally detected in the blood of a healthy person - Presence indicates colorectal cancer 2. Stool test / Fecal analysis a. Stool for Occult Blood (Guaiac Stool Exam) - Done to detect GI bleeding (upper and lower GI) - Nursing Responsibility: i.  fiber diet 48-72 hours before the test ii. No red meats, poultry, fish, turnips iii. Withhold for 48hrs: Iron, Steroids, Indomethacin, Colchicine  Iron causes blackish/greenish discoloration of stool  Steroids, Indomethacin, Colchicine may cause GI irritation leading to bleeding iv. 3 stool specimen (3 successive days) b. Stool for Ova and Parasites - Nursing Responsibility: i. Send fresh, warm stool specimen c. Stool Culture - Nursing Responsibilty: i. Sterile test tube / cotton-tipped applicator in collecting specimen d. Stool for Lipids - Nursing Responsibility: i. Assess for steatorrhea ii.  fat diet, no alcohol (3days) iii. 72-hour stool specimen (store on ice) iv. No mineral oil, neomycin SO4 3. Breath Tests a. Hydrogen breath test - Used to evaluate carbohydrate absorption, in addition to aiding in the diagnosis of bacterial overgrowth in the intestine and short bowel syndrome b. Urea breath test - Detects the presence of H. pylori that normally lives in the stomach lining and cause PUD - Nursing Responsibility: i. Avoid antibiotics or loperamide for 1 month before the test ii. Avoid sucralfate and omeprazole for 1 week before the test iii. Avoid antihistamine (e.g. Ranitidine) for 24 hours before the test 4. Abdominal Ultrasonography - Use of high-frequency sound waves to detect enlarged gallbladder or pancreas, presence of gallstones, enlarged ovary, ectopic pregnancy or appendicitis - Nursing Responsibility: i. Instruct patient to fast for 8-12hours Page 7 of 29  ii. Laxative as ordered to  bowel gas 5. Imaging Studies a. UGIS (Upper GI Series/Barium Swallow) - It is used to visualize esophagus, stomach, duodenum, and jejunum after the introduction of a contrast agent (Barium sulfate) per orem - Nursing Ressponsibility: i. NPO for 6 – 8 hours ii. X-ray taken on standing or lying position iii. After the procedure: o Laxative as ordered o Increase fluid intake o Inform the client that the stool is white for 24-72hours o Observe for BaSO4 impaction: distended abdomen, constipation b. LGIS (Lower GI Series/Barium Enema) - Used to visualized colon for presence of polyps, tumors, lesions, or anatomic malfunctions after the introduction of BaSO4 per rectum - Nursing Responsibiity: i. Instruct low residue / clear liquid diet for 2 days ii. Laxative for cleansing the bowel as ordered iii. Suppository / cleansing enema in AM iv. Discontinue enemas in patients with active inflammatory disease of the colon v. After the procedure: (same as UGIS) c. Computed Tomography - Uses beam of radiation to assess cross sections of the body Page 8 of 29 - Nursing Responsibility: i. Instruct liquid diet in AM ii. If done with contrast medium: o NPO for 2-4hours o Assess of allergy to seafoods and iodine iii. Inform the client that the procedure is painless iv. Advise the client to remain still during the entire procedure d. Magnetic Resonance Imaging - Produces cross-sectional images of organs by using magnetic fields - Nursing Responsibility: i. Instruct NPO for 6-8hours ii. Instruct to remain still during the procedure iii. Instruct that the procedure lasts for 60-90min iv. Remove jewelries / metals v. Contraindications: o Patient with pacemakers o Aneurysm clips o Orthopedic screws o Claustrophobias 6. Endoscopic Procedures a. UGI Endoscopy - Direct visualization of the esophagus, stomach and duodenum through a lighted endoscope - Used to detect esophageal, gastric or duodenal abnormalities or inflammatory, neoplastic or infectious processes are suspected - Nursing Responsibility: i. Obtain written consent ii. NPO for 6-8hours iii. Anticholinergic (AtSO4) as ordered iv. Sedatives, narcotics, tranquilizers e.g. Diazepam, Meperidine HCl v. Remove dentures, bridges vi. Local spray anesthetic on posterior pharynx vii. After the procedure: o Side-lying position o NPO until gag reflex returns (2-4hours) o NSS gargle; throat lozenges o Monitor VS o Assess for bleeding, crepitus (neck), fever, neck/throat pain, dyspnea, dysphagia, back/shoulder pain o Advise to avoid driving for 12 hours if sedative was used Page 9 of 29  b. LGI Endoscopy (Anoscopy, Proctoscopy, Sigmoidoscopy, and Colonoscopy) - Endoscopic examination of the anus, rectum, sigmoid colon, descending, transverse and ascending colon to evaluate chronic diarrhea, fecal incontinence, ischemic colitis, lower GI hemorrhage, ulceration, abscesses, tumors, polyps, etc. - Nursing Responsibility: i. Obtain written consent ii. Clear liquid diet 24 before the test iii. Administer cathartic / laxative as ordered iv. Cleansing enema v. Instruct knee – chest or lateral position during the examination vi. After the procedure: o Supine position for few minutes o Assess for signs of perforation o Hot sitz bath for discomfort in the anorectal area o Monitor VS (note for vasovagal response, e.g. bradycardia, hypotension) c. Endoscopy through ostomy - Endoscopic procedure through an ostomy stoma is useful for visualizing a segment of the small or large intestine and may be indicated to evaluate anastomosis for recurrent disease, or to visualize and treat internal bleeding. - Nursing responsibility: i. Same as other endoscopic procedure 7. Gastric Analysis - Yields information about the secretory activity of the gastric mucosa; measures secretion of HCl and pepsin - Useful in diagnosing Zollinger-Ellison syndrome or atrophic gastritis - Nursing Responsibility: i. NPO for 12 hours ii. NGT is inserted, connected to suction iii. Gastric contents collected every 15 minutes to 1hour - Common results of Gastric Analysis: COMMON DISEASES HCL ANALYSIS Pernicious Anemia HCl Atrophic or Gastric Cancer HCl Peptic Ulcer (Gastric) None or HCl Peptic Ulcer (Duodenal) HCl Zollinger – Ellison Syndrome HCl Page 10 of 29  8. Laparoscopy - An invasive procedure, usually under general anesthesia, done by making a small incision lateral to the umbilicus allowing the insertion of the fiberoptic laparoscope. - This permits direct visualization of abdominal organs for detecting abnormal growths, anomalies, and inflammatory processes - One of the benefits of this procedure is that after visualization of a problem, excision can then be performed at the same time II. Common Gastrointestinal Interventions A. Gastrointestinal Intubation 1. Types of GI tube a. Levin tube b. Salem-Sump tube c. Miller-Abbot tube d. Cantor tube e. Sengstaken – Blakemore tube - A triple-lumen tube used to treat bleeding esophageal varices (balloon tamponade) - It has two balloons: i. Esophageal balloon – to compress bleeding varices ii. Gastric balloon – to anchor S-B tube in the stomach - The esophageal balloon is inflated for 48 hours only to prevent tissue necrosis - Nursing Responsibility: i. Prevent ASPIRATION o Encourage to expectorate at regular basis o Suction the mouth PRN ii. Observe for signs and symptoms of respiratory obstruction o Gastric balloon may rupture and esophageal balloon may obstruct airway (keep pair of scissors readily available) iii. Provide oronasal care every 1-2 hours iv. Lubricate nostrils with water-soluble ointment Page 11 of 29  v. To remove S-B tube, deflate esophageal balloon before the gastric balloon to prevent upward displacement of the esophageal balloon into the pharynx causing airway obstruction B. Nasogastric Tube Insertion 1. Purposes - To provide feeding (gastric gavage) - To irrigate the stomach (gastric lavage) - For decompression - To administer medications - To administer supplemental fluids 2. Nursing Interventions during NGT Insertion - Verify doctor’s order - Inform the client and explain the procedure - Measure the length of NGT to be inserted  Tip of the NOSE to the tip of the EARLOBE to the XIPHOID PROCESS = 50cm - Lubricate tip of the tube with water-soluble jelly - Hyperextend the neck, gently advance the tube toward the nasopharynx - Tilt the patient’s head forward once the tube reaches orophayrynx and ask to swallow - Assess the placement of the tube - Secure the NGT by taping it to the bridge of the nose 3. Administering tube feeding - Assist client to a Fowler’s position or sitting position - Assess tube placement and patency:  Introduce 5-20mL of air into the NGT and ausculate at the epigastric area if gurgling sound is heard  Aspirate gastric content, which is yellowish or greenish in color  Immerse tip of the tube in water, no bubbles should be produced  Measure the pH of aspirated fluid which should be acidic  Ask the client to speak or hum  Observe the client for coughing or choking  Radiographic verification – most effective - Assess residual feeding contents. If 50ml or more, verify if the feeding will be given - Introduce feeding slowly. - Height of feeding is 12 inches above the tube’s point of insertion into the client - Instill 60mL of water into NGT after feeding. To cleanse the lumen of the tube - Clamp the NGT before all of the water is instilled - Ask the client to remain in Fowler’s position for at least 30min to prevent potential aspiration of feeding - Do after care of equipment - Documentation C. Administering Gastrostomy or Jejunostomy Feeding - Verify doctor’s order - Assist client to a Fowler’s position or sitting position - Insert feeding tube into the ostomy opening 10-15cm (4-6in) if one is not sutured in place. (Lubricate tube before insertion) - Check the patency of the tube sutured in place – pour 15 to 30 ml of water into the asepto syringe Page 12 of 29  - Assess residual feeding contents. If 50ml or more, verify if the feeding will be given - Introduce feeding slowly. Hold syringe 7-15cm(3-6in) above ostomy opening - Instill 30mL of water after feeding. To cleanse the lumen of the tube - Ask the client to remain in Fowler’s position or slightly elevated right lateral position at least 30min - Assess status of peristomal skin - Documentation D. Common Problems of the Tube Feedings 1. Vomiting 2. Aspiration 3. Diarrhea 4. Constipation 5. Hyperglycemia 6. Abdominal distention E. Administering Total Parenteral Nutrition (TPN) - Indications:  Major GI diseases, fistulas or inflammatory disease  Severe trauma or burns  Severe GI side effects from radiation or chemotherapy  Severe malnutrition  Need for extensive support over an extended period - Usual site of TPN catheter insertion is subclavian vein threaded into the superior vena cava, into the right atrium. - Place the client in T-burg position during insertion of TPN catheter - The primary purpose of TPN is to administer glucose (25-35% dextrose) - Administer TPN solution at room temperature - Consumed prepared formulas within 24 hours to prevent contamination - Maintain a steady infusion rate - Do not attempt to “catch up” if infusion is delayed - Monitor urine and blood glucose levels - Care of catheter insertion site:  Practice strict aseptic technique  Cleanse site with antiseptic solution and change sterile dressings daily  Monitor for signs and symptoms of infection - Provide good oral hygiene F. Administering Enemas Page 13 of 29  - Purposes:  To relieve constipation  To relieve flatulence  To administer medications  To lower body temperature  To evacuate feces in preparation for diagnostic procedure or surgery 1. Types of Enema a. Cleansing enema b. Carminative enema c. Retention enema d. Return flow enema / Colonic Irrigation e. Non-retention enema 2. Nursing Interventions In Enema Administration - Check the doctor’s order - Provide privacy and relaxation - Position:  Adult – left lateral / Sim’s position  Infant / Small children – dorsal recumbent - Lubricate 5 cm(2in) of the rectal tube - Allow solution to flow through the connecting tubing and rectal tube to expel air - Insert 7-10 cm (3-4in) of the rectal tube gently ,rotating motion - Introduce solution slowly - Change position to distribute solution well in the colon (high enema). Remain in left position (low enema). - Alternate hypotonic solution with isotonic solution to prevent water intoxication - If abdominal cramps occur during introduction of solution, temporarily stop the flow until peristalsis relaxes - After introduction of the solution, press buttocks together to inhibit the urge to defecate - Ask the client who is using the toilet not to flush it - Do perineal care - Documentation III. Management of the Patients with Gastrointestinal Disorders A. Achalasia - Absent or ineffective peristalsis of the distal esophagus accompanied by failure of the esophageal sphincters to relax in response to swallowing  Signs and Symptoms - Dysphagia - Sensation of food sticking in the lower portion of the esophagus - Regurgitation - Chest pain - Heartburn (Pyrosis)  Diagnostic Tests Page 14 of 29  1. X-ray 2. Barium swallow, CT scan and endoscopy 3. Manometry – measures esophageal pressure; confirmatory test  Collaborative Management 1. Instruct to eat slowly and drink fluids with meals 2. Botulinum toxin (Botox) - It inhibits the contraction of smooth muscle decreasing pressure and improve swallowing 3. Pneumatic dilation - A procedure wherein a dilator is passed, guided by a guide wire; when the balloon is in proper position, it is distended by pressure sufficient to dilate the narrowed distal esophagus - Moderate sedation during insertion is usually done 4. Surgery: Esophagomyotomy B. Hiatal Hernia - A condition wherein the opening in the diaphragm through which the esophagus passes becomes enlarged and part of the upper stomach moves up in the lower portion of the thorax - Two types: 1. Sliding esophageal hernia – the stomach and gastroesophageal junction have moved upward and slide in and out of the thorax 2. Paraesophageal hernia – all or part of the stomach pushes through the diaphragm next to the gastroesophageal junction  Causes  Muscle weakness in the esophageal hiatus: - Aging process - Congenital muscle weakness - Obesity - Trauma - Surgery - Prolonged increase of intraabdominal pressure  Signs and Symptoms - Heartburn Page 15 of 29  - Regurgitation - Dysphagia - Gastric reflux does not occur because the gastroesophageal junction is still intact  Diagnostic Tests 1. X-ray 2. Barium swallow 3. fluoroscopy  Medical Management 1. Pharmacologic Treatment a. Antacids, Antiemetics, H2 blockers b. Avoid: Anticholinergic, Ca-channel blockers, diazepam - These drugs lower the LES (lower esophageal sphincter) pressure 2. Surgical Treatment  Nissen Fundoplication (gastric-wrap around) a. Preop Care i. Teach DBE and assist in the use of incentive spirometer ii. Inform possible postop contraptions: NGT, chest tube b. Postop Care i. Facilitate airway clearance ii. Semi-Fowler’s position iii. DBE, incentive spirometry, CPT iv. NGT care v. Drainage is yellowish green for the first 8-12 hours vi. Clear liquids after peristalsis returns  Nursing Interventions 1. Modify diet: high CHON diet to enhance LES pressure 2. Small frequent feedings; eat and chew foods properly 3. Avoid fatty foods, cola, coffee, chocolate and tea 4. Advise not to recline 1 hour after eating 5. Avoid smoking C. Diverticulum - An outpouching of mucosa and submucosa that protrudes through a weak portion of the musculature - It may occur in one of the 3 areas of the esophagus: i. Pharyngoesophageal or upper esophagus ii. Midesophageal area iii. Epiphrenic or lower esophagus - Most common type: Zenker’s diverticulum (pharyngoesophagealpulsion diverticulum or pharyngeal pouch) Page 16 of 29  Signs and Symptoms - dysphagia - regurgitation of undigested food - fullness in the neck - gurgling noises after eating - belching - halitosis  Diagnostic Tests 1. Barium swallow 2. Manometry 3. Esophagoscopy, usually contraindicated because of the danger of perforating diverticulum  Collaborative Management 1. Surgical Treatment a. Diverticulectomy - Surgical removal of the diverticulum b. Myotomy - Performed to relieve spasticity of the musculature preventing continuation of the previous symptoms 2. NGT insertion D. Gastroesophageal Reflux Disease (GERD) - Backflow of gastric or duodenal contents into the esophagus  Causes 1. Incompetent lower esophageal sphincter 2. Pyloric stenosis 3. Motility disorder 4. Aging  Signs and Symptoms - Pyrosis - Odynophagia - Dyspepsia: indigestion - Hypersalivation - Regurgitation - Can imitate anginal attack - Dysphagia  Diagnostic tests 1. Endoscopy 2. Barium swallow 3. Esophageal pH monitoring 4. Bilirubin monitoring  Collaborative Management 1. Pharmacologic treatment a. Antacids or H2 blockers [famotidine(Pepcid), ranitidine (Zantac)] b. Proton Pump Inhibitors [Omeprazole(Omepron)] 2. Surgical treatment: Nissen-Fundoplication 3. Low fat diet. To enhance lower esophageal sphincter pressure 4. Avoid caffeine, smoking, beer, milk and cola 5. Avoid eating or drinking 2 hours before bedtime 6. Elevate HOB 6-8” 7. Elevate upper body on pillows Page 17 of 29  E. Gastritis - Diffuse or localized inflammation of the gastric mucosa - 2 Types: 1. Acute Gastritis  Short-term (several hours to few days) inflammatory process due to ingestion of chemical agents or food products that irritate and erode gastric mucosa 2. Chronic Gastritis  Resulting from repeated exposure to irritating agents or recurring episodes of acute gastritis  2 forms: i. Type A: autoimmune in nature, gastric Ca, pernicious anemia ii. Type B: associated with H. pylori infection  Causes 1. Dietary Indiscretion / Unhealthy diet 2. Overuse of NSAIDs (aspirin) 3. Excessive alcohol intake 4. Bile reflux 5. Radiation therapy 6. H. pylori infection  Signs and Symptoms - Anorexia - Nausea and vomiting - Abdominal cramping - Diarrhea - Epigastric pain - Fever - Painless GI bleeding (due to ASA/NSAIDs) - Pyrosis  Diagnostic Tests 1. UGI x-ray series 2. Endoscopy 3. Histologic examination  Collaborative Management 1. Pharmacologic treatment - Antacids, H2 blockers, Sucralfate 2. Bland or liquid diet until pain resolves 3. Fluid – electrolyte replacement 4. Vitamin B12 if pernicious anemia occurs 5. Avoid alcohol, smoking 6. Avoid overeating Page 18 of 29  F. Peptic Ulcer Disease - Generic term for disorders characterized by excavation in any segment of the GI mucosal wall (esophagus, stomach, pylorus, duodenum) secondary to hyperacidity. - Two common types: i. Gastric Ulcer ii. Duodenal Ulcer  Predisposing Factors 1. Stress Pancreatic Tumor (gastrinoma) 2. Cigarette smoking gastric secretion  HCl 3. Alcohol secretion multiple areas of 4. Caffeine ulcerations 5. Drugs (ulcerogenic drugs: ASA, 8. Eating hurriedly and not eating NSAIDs, Steroids) 9. Fatty, spicy, highly acidic foods 6. H. pylori infection 10. Type A personality 7. Zollinger – Ellison Syndrome 11. Type O blood 12. Genetics  Signs and Symptoms GASTRIC ULCER DUODENAL ULCER Pain radiates on the left epigastrium Pain radiates on the right epigastrium 30min – 1hr pc 2 – 3 hrs pc Aggravated by food Relieved by food Relieved by vomiting No vomiting occurs Decreased HCl Increased HCl Hematemesis Melena Occasionally malignant Rarely malignant  Diagnostic Tests 1. Barium Swallow 2. UGI endoscopy 3. Biopsy of suspicious lesions 4. Gastric Analysis - Diagnosing achlorhydria and ZES  Medical – Surgical Management 1. Pharmacologic Therapy a. Hyposecretory Agents  H2 blocker (e.g. Ranitidine), given ac  Proton Pump Inhibitor (e.g. Omeprazole), given ac  Prostaglandin analogue (e.g. Cytotec) b. Antacid agents - Neutralizes HCl - Taken 1 -2 hrs pc  AlOH (Amphogel)  MgOH (Milk of Magnesia, Novaluzid) Page 19 of 29   AlMgOH (Maalox, Simeco) c. Cytoprotective Drugs / Barrier Fortifiers - Coats ulcer - Given 1hr ac  Carafate (Sucralfate) d. H. pylori Drug Treatment  Pepto-Bismul (bismuth compound)  Amoxicillin / Tetracycline  Flagyl (Metronidazole). Avoid alcohol to prevent disulfiram-like reactions 2. Surgical Treatment a. Vagotomy  Resection of the vagus nerve  Decreases cholinergic stimulation HCl secretion and and gastric motility b. Pyloroplasty  Surgical dilatation of the pyloric sphincter  Improves gastric emptying of acidic chime c. Antrectomies / Gastrectomy  Removal of 50% of the lower part of the stomach  Types: i. Billroth I (gastroduodenostomy) ii. Billroth II (gastrojejunostomy) o The duodenum is bypassed to permit the flow of the bile from the common bile duct d. Subtotal Gastrectomy  Removal of 75% of the distal stomach with Billroth I or Billroth II repair  Nursing Responsibility on Gastric Surgery i. Preop Care  Provide psychosocial support  Teach DBCT exercises  Provide nutritional support – TPN as ordered  Inform about postop measures: NGT and TPN until peristalsis returns ii. Postop Care  Promote patent airway and ventilation: o Semi-Fowler’s position o Reinforce DBCT exrcises, incentive spirometry o Administer analgesics before activities o Splint incisions before the patient coughs o Encourage early ambulation  Promote adequate nutrition: o NPO until peristalsis returns Page 20 of 29  o NGT care o TPN care  Prevent potential complications: i. Signs of Bleeding ii. Dumping Syndrome  Nursing Interventions 1. Relieve Pain 2. Promote healthy lifestyle - Avoid / prevent all predisposing factors of PUD 3. Quit smoking 4. Stress Therapy / Coping G. Gastric Cancer - Cancer, which is mostly adenocarcinomas, that can occur anywhere in the stomach - Common in middle-age males  Causes 1. Excessive intake of nitrite-cured, salt-cured and smoke-cured foods 2. Low fiber diet 3. Cigarette smoking 4. Chronic achlorhydria 5. Pernicious anemia 6. Villous adenoma 7. Heredity 8. Excessive intake of raw foods 9. Atrophic gastritis  Signs and Symptoms - Progressive loss of appetite - Palpable abdominal mass - Gastric fullness (early (e.g. ascites, hepatomegaly) satiety) - Achlorhydria - Dyspepsia - Sister Mary Joseph’s nodule - Nausea and vomiting (sign of GI malignancy) - Hematemesis / melena - Pain induced by eating, - Weight loss, fatigue, relieved by vomiting (late anemia symptom)  Diagnostic tests 1. Barium x-ray of the UGIT 2. Esophagogastroduodenoscopy for biopsy (Dx of choice) 3. Endoscopic ultrasound 4. CT scan  Collaborative Management 1. Surgery a. Total Gastrectomy b. Radical subtotal gastrectomy i. Billroth I ii. Billroth II 2. Chemotherapy 3. TPN prn Page 21 of 29  4. Prevent Dumping Syndrome 5. Vitamin B12 per IM H. Appendicitis - Inflammation of the vermiform appendix  Causes 1. Obstruction by fecalith or foreign bodies, bacterias, and toxins 2. Low fiber diet 3. High intake of refined carbohydrates  Signs and Symptoms - Vague epigastric or periumbilical pain that progresses to the RLQ (McBurney’s point) - Blumberg sign (rebound tenderness) - Psoas sign (lateral position with right hip flexion) - Rovsing’s sign (paradoxical pain felt on the RLQ when palpated on the LLQ) - Anorexia, nausea and vomiting - Low-grade fever - Decreased or absent bowel sound  Diagnostic Test 1. CBC 2. X-ray, UTZ, and CT scans 3. Laparoscopy  Medical Management 1. Surgery – Appendectomy - Surgical removal of the appendix - Spinal anesthesia - If ruptured appendicitis occurs, a penrose drain may be placed to drain the abscess - Nursing responsibility: i. Flat on bed for 6-8hours postop ii. Monitor for return of sensation in the lower extremities iii. NPO until peristalsis returns iv. Ambulation after 24 hours and other related exercises 2. Analgesics as ordered 3. Antibiotic therapy  Nursing Management 1. Bed rest 2. NPO 3. Relieve pain (cold application over the abdomen) 4. Avoid factors that increase peristalsis, thereby rupture: - Heat application over the abdomen - Laxative - Enema 5. IVF therapy to maintain fluid-electrolyte balance Page 22 of 29  I. Diverticular Disease I.1 Diverticulum – Saclike outpouching of the lining of the bowel that extends through a defect in the muscle I.2 Diverticula / diverticulosis – multiple outpouching without inflammation or symptoms I.3 Diverticulitis – acute inflammation and infection caused by trapped foods, bacteria and fecal material in a diverticulum  Causes 1. Low fiber diet 2. Aging  Signs and Symptoms - Crampy LLQ pain - Low-grade fever - Chronic constipation - Nausea and vomiting - Abdominal distention and tenderness - Narrow stools - Occult bleeding - s/sx of peritonitis due to development of abscess or perforation  Diagnostic Tests 1. Colonoscopy 2. Barium enema 3. CT scan and abdominal x-ray 4. CBC  Medical Management 1. Diet - Clear liquid High fiber, low fat 2. Pharmacologic Treatment a. Analgesics (opioid except morphine) b. Antibiotics c. Bulk-forming laxatives (Metamucil) d. Antispasmodics (Pro-Banthine) 3. Surgical Treatment a. Hartmann procedure - Removal of area of diverticulitis and the remaining bowel is joined end-to-end  Nursing Management 1. Encourage high fiber diet 2. Liberal fluid intake of 2,500 to 3,000 mls/day 3. Avoid nuts and seeds which can become trapped in the diverticula 4. If signs of infection is still present, avoid high fiber diet to prevent GI irritation 5. Bed rest 6. Weight loss to reduce intraabdominal pressure Page 23 of 29  J. Peritonitis - Inflammation of the peritoneum caused by the following: i. Ruptured appendicitis ii. Perforated peptic ulcer iii. Diverticulitis iv. Pelvic inflammatory disease v. UTI or trauma  Signs and Symptoms - Diffuse abdominal pain - Abdominal guarding / rigidity / “boardlike” abdomen - Nausea and vomiting - Diminished bowel sounds - Paralytic ileus - Fever - Signs of early shock:  HR,  RR,  urine output, etc.  Diagnostic Tests 1. CBC, serum electrolytes 2. Abdominal x-ray 3. CT scan 4. Peritoneal aspiration and cultures  Complications 1. Sepsis 2. Shock  Medical Management 1. Fluid, colloid and electrolyte replacement – IVF 2. Pharmacologic treatment a. Analgesics b. Massive antibiotic therapy 3. O2 therapy 4. Surgery to drain infected materials and correct the cause  Nursing Management 1. Monitor VS regularly 2. Proper positioning – fetal position 3. Care of drains postop and assessing its drainage characteristics Page 24 of 29  K. Chronic Inflammatory Bowel Disease  Types 1. Regional Enteritis (Crohn’s disease) - A subacute and chronic inflammation of the GI tract wall that extends through all layers. Though all layers could be affected, it is commonly seen in the distal ileum and ascending colon 2. Ulcerative Colitis - A recurrent ulcerative and inflammatory disease of the mucosal and submucosal layers of the colon and rectum  Differentiation of the 2 Types Crohn’s Disease Ulcerative Colitis Causes Unknown Unknown Familial history (more common) Familial history (less common) Autoimmune Bacterial infection Emotional stress Immunologic factors / Environment Age 20 – 30 yrs 15 – 40 yrs 40 – 60 yrs Stool and Bleeding  ; stool with pus and mucoid; Severe; stool with blood, pus and steatorrhea mucus; tenesmus Diarrhea 3 – 5x a day 15 – 20x a day Pain RLQ Generalized crampy abdominal pain (LLQ) Page 25 of 29  Weight loss Present Present Lesions Peyer’s patches: “cobblestone- Crypt abscess like” Fistulas Common Rare  Diagnostic Tests (Crohn’s disease) 1. Stool examination (Occult blood) 2. Barium Study – reveals “string sign” of the terminal ileum 3. Endoscopy, colonoscopy, intestinal biopsies 4. CT scan 5. CBC  Diagnostic Test (Ulcerative Colitis) 1. Stool exam 2. CBC 3. Abdominal x-ray 4. Proctosigmoidoscopy and Ba enema 5. CT scan  Medical Management of CIBD 1. Nutritional Therapy a. Increased oral fluids,  protein,  caloric, low-residue diet with vitamin supplement b. Any foods that exacerbate diarrhea should be avoided c. TPN – glucose + amino acids (Nutrimix) 2. Pharmacologic treatment a. Antibiotics [e.g. metronidazole (Flagyl)] b. Corticosteroids [e.g. prednisone, hydrocortisone] c. Immunomodulators [e.g. methotrexate] d. Antidiarrheal 3. Surgical treatment – Colon Surgery a. Ileostomy / colectomy (Crohn’s disease) b. Ileostomy / Proctocolectomy (Ulcerative colitis) c. Proctocolectomy with Ileal Pouch Anal Anastomosis L. Colorectal Cancer  Causes 1. Aging 2. Genetics 3. Previous colon cancer 4. History of inflammatory bowel disease 5. High fat, high protein, low fiber diet 6. Genital cancer or breast cancer  Signs and Symptoms 1. Ascending (Right) Colon Cancer - Occult blood in stool - Anemia - Anorexia and weight loss - Abdominal pain above umbilicus Page 26 of 29  - Palpable mass 2. Distal Colon / Rectal Cancer - Rectal bleeding - Changed in bowel habits - Constipation or diarrhea - Pencil or ribbon-shaped stool - Tenesmus - Sensation of incomplete bowel emptying  Diagnostic Tests 1. GUAIAC test, Ba enema, proctosigmoidoscopy and colonoscopy 2. Biopsy and cytology smears 3. CEA studies  Guidelines for Early Detection of Colorectal Cancer 1. Digital rectal examination after age 40 2. Occult blood test yearly after age 50 3. Proctosigmoidoscopy every 5 years after age 50, following 2 negative results of yearly examination  Medical Management 1. Surgery a. Hemicolectomy for ascending and transverse colon cancer b. Abdomino – Perineal Resection (APR) for rectosigmoid cancer o There are 2 incisions: lower abdomen incision to remove the sigmoid; perineal incision to remove the rectum o T – binder is used to secure perineal dressing o Necessitates permanent colostomy 2. Chemotherapy - Fluorouracil is the most effective drug for colorectal cancer 3. Radiotherapy - Adjuvant treatment for rectal cancer  Nursing Management 1. Colostomy Care a. Diet -  fiber diet - Avoid gas-forming and foul odor – forming foods(dairy products, fish, CHO, cabbage, carbonated beverages) b. Skin care - Clean with plain soap and water - Apply skin barriers c. Colostomy irrigation - Done to stimulate peristalsis and reestablish bowel habits - Done 4th – 6th day post-operatively - Perform colostomy irrigation after meal at the toilet - Advise to seat on the commode while on irrigation - Hang the irrigation solution 12-18 inches above the stoma - Clamp the tubing if abdominal cramps occur and continue until it relaxes - Allow the solution to remain for 5-10min then remove the catheter to drain for 15- 20min - Clean the stoma, apply new pouch Page 27 of 29  M. Dumping Syndrome - Rapid emptying of the hypertonic chime of the stomach  Early signs and symptoms - Weakness - Tachycardia - Dizziness - Diaphoresis - Pallor - Feeling of fullness or discomfort - Nausea - Explosive diarrhea, abdominal cramps, borborygmi  Late signs and symptoms - Hyperglycemia increased insulin secretionhypoglycemia  Collaborative Management 1. Eat in recumbent or semi – recumbent position 2. Lie down after meal (left side) 3. Small, frequent feedings 4. Moderate fat, high protein diet. Fats slow down gastric motility; proteins increase colloidal osmotic pressure and prevent shifting of plasma 5. Limit carbohydrates, no simple sugars 6. Give fluids after meals 7. Avoid very hot and cold foods and beverages 8. Anticholinergic or antispasmodic as ordered N. Hemorrhoids - Dilated blood vessels beneath the lining of the skin in the anal canal  Two Types 1. External hemorrhoids – occur below the anal sphincter 2. Internal hemorrhoids – occur above the anal sphincter Page 28 of 29  Causes 1. Chronic constipation 2. Pregnancy 3. Obesity 4. Prolonged sitting or standing 5. Wearing constricting clothings 6. Disease conditions like liver cirrhosis, RSCHF (right sided congestive heart failure)  Signs and Symptoms - Constipation - Anal pain - Rectal bleeding - Anal itchiness - Mucous secretion from the anus - Sensation of incomplete evacuation of the rectum - Internal hemorrhoids may prolapsed  Collaborative Management 1. High fiber diet, liberal fluid intake 2. Bulk laxatives 3. Hot sitz bath, warm compress 4. Local anesthetic application – Nupercaine 5. Surgery: i. Hemorrhoidectomy ii. Cryosurgery iii. Rubber band ligation Page 29 of 29