4.1 Care of Upper/Lower GI System Flashcards
Abdominal Regions
Right Hypochondriac Epigastric Left Hypochondriac
Right Lumbar Umbilical Left Lumbar
Right Iliac Hypogastric Left Iliac
Major Functions of GI Tract
- Digestion
- Absorption
- Elimination
Major Enzymes of GI System
- Saliva/Salivary Amylase (Chewing and Swallowing)
- Hydrochloric Acid, Pepsin, Intrinsic Factor (Gastric Function)
- Amylase, Trypsin, Bile (Small Intestines)
History of Present Illness
- Abdominal Pain
- Dyspepsia (indigestion)
- Flatulence
- N/V
- Diarrhea
- Constipation
- Fecal Incontinence
- Jaundice
Pain
- Onset
- Location
- Duration
- Characteristics
- Aggravating Factors
- Relieving Factors
- Time
- Distribution of referred pain
Abdominal Pain
- May be referred from area of dysfunction to nearby or remote locations
Common Issues
Dyspepsia - The most common GI dysfunction
Intestinal Gas - Ask about bloating, distention, flatulence, food intolerances, gallbladder disease
N/V - Vague and uncomfortable
Other Issues
Change in bowel habits/stool characteristics
- Can be sign of colonic dysfunction or disease. (Constipation/Diarrhea)
Past health, family, social history
- Oral care, dentist visits, lesions in mouth, discomfort with foods, alcohol/tobacco, dentures.
Assessment of Oral Cavity
- Lips, tongue, gums
Rectal Inspection
- Done as appropriate
GERD (Gastroesophageal Reflux Disease)
- There is no single cause
- Reflux of hydrochloric acid and pepsin from stomach into lower esophagus causing irritation and inflammation.
- Intestinal proteolytic enzymes (trypsin) and bile salts add to irritation
GERD Risk Factors
- Obesity due to increased intra-abdominal pressure
- Hiatal Hernia (stomach bulges into diaphragm)
- Decreased esophageal clearance
- Decreased gastric emptying
Primary Factor of GERD
- Results in decreased pressure in distal portion of esophagus
- Patient must report several episodes of reflux for diagnosis of GERD
- Gastric contents move from stomach to esophagus
- Can be due to caffeine, chocolate, anticholinergics
Complications of GERD
- Related to direct local effect of gastric acid on the esophageal mucosa
Barrett’s Esophagus
- Esophageal metaplasia
- Development of pre-cancerous lesions
Esophagitis
- Inflammation of Esophagus
- Repeated exposure results in esophageal stricture (tightening of esophagus) which results in dysphagia
GERD Diagnostic
- Endoscopy
Management of GERD
- Lifestyle modifications
- Low fat diet
- Avoidance of caffeine, tobacco, beer, milk, peppermint/spearmint, and carbonated drinks
- Avoid eating or drinking 2-3 hours before bedtime
- Elevated head of bed by 30 degrees
Hiatal Hernia/Diaphragmatic Hernia/Esophageal Hernia
- Herniation of esophagogastric junction and lower portion of stomach into the chest through the esophageal hiatus of diaphragm
- Most common abnormality found on x-ray of UGI tract
Types of Hiatal Hernia’s
Sliding - Most common type (slides in and out of your chest)
Rolling (Paraoesophageal) - Medical Emergency (stomach protrudes up through a hole in the diaphragm)
Etiology of Hiatal Hernia
- Weakening of muscles in diaphragm possibly due to aging
- Increased intraabdominal pressure from obesity
- Pregnancy
- Heavy lifting
- Ascites
- Tumors
- Intense physical exertion
Clinical Manifestations of Hiatal Hernia
- May be asymptomatic or with GERD
- Bending over causes severe burning pain relieved by sitting or standing
- Heartburn especially after eating or lying supine
- Dysphagia
- Feeling full or uncomfortable after eating
- Associated with large meals, alcohol, and smoking
Diagnostic for Hiatal Hernia
- Esophagram (barium swallowing)
- Gastroscopy
Surgical Therapy for Hiatal Hernia
- Laparoscopically surgeries are most common anti-reflux surgeries (small incisions through abdomen)
Nissen Fundoplication (creation of esophageal sphincter) via the thoracic or abdominal approach is another treatment
Peptic Ulcer Disease (PUD)
- Erosion of GI Mucosa from digestive action of HCl acid and pepsin.
- Ulceration penetrates the mucosal wall of GI tract
- Ulcers can develop in lower esophagus, lesser curvature of stomach, duodenum (most common), or margin of gastrojejunal anastomosis after surgical procedures.
- Ulcers can only develop in places with acid
Heliobacter Pylori Bacterium (H. Pylori)
- Associated with significant amount of gastric ulcers
- Produces enzyme urease which activates immune response, antibody production, and release of inflammatory cytokines.
Aspirin/NSAIDS
- Inhibits prostaglandin synthesis
- This causes increased gastric acid secretions and reduces integrity of mucosal barrier.
- Responsible for majority of Non-H. Pylori Peptic Ulcers
- NSAIDS in the presence of H. Pylori increase risk of PUD
Gastric Ulcer Clinical Manifestations
- Pain high in epigastrium
- Pain radiates to back
- Relieved by antacids
- Occurs 1-2 hours after meals
- “Burning” or “Gaseous”
- Food aggravates pain, especially if the ulcer has eroded through the gastric mucosa.
Duodenal Ulcers
- Mid-Epigastric Region beneath xiphoid process
- Back pain only happens if ulcer is located in the posterior aspect
- Occurs 2-5 hours after meal
- “Burning” or “Cramp-like”
- Tendency to occur, disappear, and occur again
Nursing Diagnosis
- Acute Pain
- Anxiety
- Imbalanced Nutrition
- Deficient Knowledge
Major Goals for Peptic Ulcer Disease
- Relief of pain
- Reduced anxiety
- Maintenance of Nutritional Requirements
- Knowledge about the management and prevention of ulcer recurrence
- Absence of Complications
Care for patient with Peptic Ulcer
- Abdominal Assessment
- Assess pain and relief methods
- Dietary intake and 72 hour diet diary
- Lifestyle modifications such as cigarettes and alcohol use
- Medications including antacids, h2 blockers, proton pump inhibitors
- Educate about signs of anemia or bleeding
Hemorrhage (PUD Complications)
- Assess for bleeding
- Hematemesis (vomiting blood that may look red or like coffee grounds)
- Melena (passage of black tarry stools)
- Symptoms of shock and anemia
TREATMENT - IV Fluids
- NG Tube
- Saline or Water Lavage (irrigation of stomach)
- Oxygen
- Monitor VS and UO (urinary output)
- May require endoscopic coagulation or surgical intervention
Perforation or Penetration
- Lethal Complication
- Severe abdominal pain that may refer to shoulder
- Vomiting and collapse
- Tender board like abdomen
- Symptoms of shock
- Requires immediate surgery when ulcer is penetrates serosal surface with spillage into peritoneal cavity
- Large perforations require immediate surgical closure
- Small perforations may spontaneously seal themselves
Pyloric Obstruction (Gastric Outlet Obstruction)
- N/V
- Constipation
- Epigastric fullness
- Anorexia and weight loss
TREATMENT - Insert NG Tube to decompress stomach
- Provide IV fluids and electrolytes
- Balloon dilation or surgery may be required
MEDICATIONS
Prokinetic Agents
- Metoclopramide (Reglan)
- Promotes gastric motility, accelerates gastric emptying
Antacids/Acid Neutralizing Agents
- Calcium Carbonate (Tums)
- Aluminum Hydroxide
- Simethicone (Maalox)
- Neutralizes gastric acid by producing neutral salts and inactivating pepsin
Proton Pump Inhibitors (PPI’s)
- Pantoprazole (Protonix)
- Omeprazole (Prilosec)
- Esomeprazole (Nexium)
- Decreases gastric secretion by slowing H+, K+ ATPase Pump
- Reduces gastric secretion by irreversibly inhibiting the enzyme that produces gastric acid
Surface Agents/Alginate-Based Barriers (Protectants)
- Sucralfate (Carafate)
- Protective barrier that adheres to an ulcer, protecting it from further injury from acid and pepsin
Reflux Inhibitors
- Bethanechol Chloride (Urecholine)
- Used mainly for urinary retention but can occasionally be used for GERD
- Used to increase muscle tone & increase lower esophageal pressure in treatment of gastric reflux
Histamine-2 (H2) Receptor Antagonist
- Famotidine (Pepcid)
- Ranitidine (Zantac)
- Cimetidine (Tagamet)
- Decreases the amount of HCL produced by the stomach by blocking the action of histamine on histamine receptors of parietal cells in the stomach
Irritable Bowel Syndrome (IBS)
- Chronic functional disorder
- Intermittent abdominal pain and stool pattern irregularities
- No cause known
- Often report GI infections and food intolerances (food allergy unclear)
- More frequent in women
- Longer and stronger contractions of intestines that disrupt movement of food causing diarrhea or constipation
- They also may have oversensitive nerves of intestinal track
IBS Diagnoses
- Based solely on symptoms
- ROME 4 Criteria - Any combination of motility disturbance, visceral hypersensitivity, altered mucosal and immune function, altered gut microbiota, altered CNS processing.
Changes from ROME 3 to ROME 4
- Pain is still essential but “discomfort” is removed
- Occurs at least one day a week
- May or may not experience pain improvement after defecation
- Change in form/frequency of stool
- Pain and change in stool frequency don’t always coincide
IBS Categories
- IBS with constipation
- IBS with diarrhea
- IBS mixed
- IBS unsubtyped
Dietary Considerations for IBS
- No single therapy effective for all patients
- Gradually increase fiber (>20g/day) and stool bulking agents (gradually to reduce gas)
- Eliminate gas producing foods (beans, brussel sprouts, cabbage, cauliflower, raw onions, grapes, plums, raisins)
- Eliminate fructose and sorbitol
- Yogurt may be better tolerated than milk
- Probiotics may be used (alterations in bacteria are believed to exacerbate symptoms)
FODMAPs
- Carbohydrates (sugar) that contribute to IBS sufferers F - Fermentable O - Oligo-saccharides D - Di-saccharides M - Mono-saccharides A - And P - Polyols
These include fructose, lactose, fructans, galactans, and polyols.
- Review patient food that is high in FODMAP’s and teach to use low FODMAP diet. Follow regime for 6-8 weeks then gradually introduce new foods based on provider direction.
Nursing Care of IBS
- Identify relationship between diarrhea and food, activities, or emotional stressors
- Provide ready access to bathroom or commode
- Encourage bed rest to reduce peristalsis
- Administer medication as prescribed
- Record frequency/consistency/character and amount of stool
Patient Education for IBS
- Daily weight
- Understanding symptoms of dehydration/fluid loss
- Encourage oral hydration
- Nutrition/dietary modifications
- Diversional activities
- Prevention of fatigue
- Medications Possible ileostomy care
Inflammatory Bowel Disease (IBD)
- Inflammation of GI Tract
- Ulcerative Colitis vs Crohn’s Disease
- Cause is unknown but involve genetics and alteration in function of immune system
- Onset peaks at age 15-25
- Second peak is in 6th decade
- No cure
IBD
- Autoimmune disease with immune reaction to own intestinal tract
- Triggers cause an overactive sustained immune response that results in widespread inflammation and tissue destruction
- Periods of remission and periods of exacerbation
Crohn’s Disease (IBD)
- Involves any segment of GI Tract from mouth to anus
- NOD2 bacterial sensor is a gene associated with CD
Ulcerative Colitis
- Usually only affects the colon
Crohn’s Disease
- Inflammation occurs anywhere in digestive tract
- Inflammation occurs in patches or “skip lesions”
- Pain commonly in LOWER RIGHT abdominal quadrant
- Bleeding from rectum uncommon
- Colon wall is thick “cobblestone”
Ulcerative Colitis
- Large intestines is typically the only affected site
- Inflammation is continuous throughout affected sites
- Pain is commonly in LOWER LEFT QUADRANT
- Bleeding is common from rectum during bowel movements
- Colon wall is thin and inner lining inflammation
Clinical Manifestations of UC
- Primary symptom includes constipation
- Bloody stools with Tenesmus (feeling of needing to pass stool even if bowels are already empty)
- Pain in left lower quadrant for moderate to severe cases
- Nausea and Vomiting not as common as CD
Clinical Manifestations of CD
- Common manifestation is abdominal cramping and pain in right lower quadrant
- Nausea and Vomiting is common
Clinical Manifestations of IBD
- Constipation/Diarrhea
- Abdominal Distention
- Excessive flatulence
- Trapped gas
- Bloating
- Fecal urgency
- Sensation of incomplete evacuation
Psychological Manifestations of IBD
- Anxiety
- Panic disorders
- Depression
- Post-traumatic stress disorder
Diagnostic Tests for IBD
- History/Physical Exam
- CBC
- Electrolytes
- Erythrocyte Sediment Rate (ESR)
- C-reactive protein (CRP)
- Stool C/S (culture and sample)
- Abdominal CT or MRI
- Colonoscopy
Care for IBD
- Balanced Diet (Nutritional Therapy)
- Drug treatment is to maintain remission
- Drugs are used to suppress proinflammatory cytokines
- Antimicrobials, corticosteroids, immunosuppressants, 5-ASA
- First use less toxic therapies then “step-up”
- “step-down” target antibodies first
Surgery for IBD
Ulcerative Colitis - Total proctocolectomy (remove large intestines, rectum, anus) with ileal pouch and anastomosis (connection)
Crohn’s Disease - Resection of diseased segments with re-anastomosis or strictureplasty
Post-OP Treatment for IBD
- At risk for Short Bowel Syndrome (SBS)
- Inadequate surface area to absorb fluids and nutrients
- Can lead to chronic diarrhea
- Issues lead to electrolyte imbalances, cardiac dysrhythmias, GI bleeding with fluid loss, and perforation of bowels.
Diverticular Disease
- Herniations or saclike outpouchings (haustra) of mucosa through muscle layers.
- Mostly located in sigmoid colon but can be anywhere from esophagus to anus
Diverticulosis
- Asymptomatic disease in presence of diverticula
Diverticulitis
- Inflammation in presence of diverticula
Diverticular Disease
- Older than age 60 Risk Factor
- Prevention through proper nutrition and high fiber diet
- Treatment focuses on dietary modification to prevent infection
Clinical Manifestations of Diverticular Disease
- Pain in lower left quadrant
- Diarrhea/Constipation
- Distention or Flatulence
- Exacerbated by eating certain foods, especially hard to digest foods like corn, nuts, seeds and popcorn.
Diagnosis of Diverticular Disease
Based on
- CBC (especially WBC count)
- Urinalysis
- Guaiac Testing of Stool
- Abdominal X-ray
- ABD Ultrasound
- CT Scan of ABD with contrast (most effective)
Management of Diverticular Disease
- High fiber diet
- Pain medication
- Antibiotics for diverticulitis (ciprofloxacin, metronidazole, cephalexin, doxycycline)
- Anticholinergics to relieve muscle spasms and reduce pain
- Severe episodes need for administering IV Fluids/IV antibiotics
- May require temporary colostomy
Complications of Diverticular Disease
- Perforations
- Peritonitis
- Abscess
- Fistulas
- Complete intestinal obstruction
- Severe bleeding
Upper GI Bleeding (UGI)
- Stomach and duodenum Most common cause - Peptic Ulcer - H. Pylori and chronic infection - Drug use such as aspirin/NSAIDs - Esophageal bleeding most likely due to esophagitis (inflammation), Mallory-Weiss tears, or esophageal varices (enlarged veins)
Dividing point between Upper and Lower GI Bleed
- Duodenojejunal Junction
Lower GI Bleeding (LGI)
- Diverticular Disease
- IBD
- Tumors
- Polyps of colon
- Hemorrhoids
- Anal Fissures
GI Bleed
Occult - Asymptomatic
Frank - Obvious
- Severity depends on if bleeding is venous, capillary, arterial
Arterial - Profuse and bright red (has not come in contact with gastric acid)
Hematemesis
- Blood that is bright red and has not come in contact with gastric contents
Vomitus
- Blood has been in stomach for some time
- “Coffee Grounds”
Melana
- Sticky, Dark Maroon, Black Tarry Stool
Hematochezia
- Passage of bright red blood through rectum
- Cause is not easy to determine
Massive Upper GI Hemorrhage
- 1500 mL of blood
- 80-85% spontaneously stop bleeding
Emergency Assessment and Management of GI Bleed
- Respiratory Status is assessed
- VS every 15-30 minutes
s/s of Shock include - Tachycardia, weak pulse, hypotension, cool extremities, prolonged capillary refill, apprehension
ABD Examination - Bowel sounds
- Tense rigid abdomen can mean perforation and peritonitis
Fluid Replacement
- IV Fluid Replacement
- Begin with isotonic crystalloid solution (NS or Lactated Ringer)
3: 1 rule - 3mL of crystalloid for every 1mL of blood loss
Blood Replacement
- Used for massive hemorrhage
- Whole blood, packed RBCs, or fresh frozen plasma
- Packed RBC’s are the preferred method due to risk of fluid overload or immune reactions
Laboratory Studies
- CBC
- Typing and crossmatching for transfusions
- Electrolytes
- Testing vomitus and stools occult blood test
- BUN during hemorrhage (blood protein is broken down in GI Tract resulting in elevated BUN)
- Prothrombin/Partial Thromboplastin time
- Liver Enzyme Measurement
NG Tube
GI Intubation
- Decompress the stomach, lavage the stomach, compress a bleeding site, aspirate gastric contents for analysis
Types of Tubes
- Lavage tubes - Cleaning stomach through irrigation
- Gastric (Salem) Sump - Double Lumen Gastric Suctioning
- Levin Tube - Used for intestinal decompression
- Blakemore Tube - Stop bleeding in stomach or esophagus
Lavage Tube
- 50-100 mL of fluid at a time
- Fluid can be aspirated or drained by gravity
- Keep HOB elevated and observe for aspirate of blood
Hemorrhage from Chronic Alcohol Abuse
- Monitor delirium tremens, agitation, uncontrolled shaking, sweating, vivid hallucinations
NG Tube Verification
- DO NOT AUSCULTATE OR ASPIRATE TO VERIFY PLACEMENT
- Use Radiography or pH measurement
