Gastrointestinal System Disorders PDF

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...

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