Module 10 - Control and Disorders of Gastrointestinal Function Flashcards
Functions of the GI System
Process food substances—dismantle & reassemble food
Produce enzymes and hormones for digestion
Absorb the products of digestion—nutrients, vitamins, minerals, electrolytes, and water
Store and synthesize vitamins
Provide an environment for microorganisms to synthesize nutrients, such as vitamin K
Collect and eliminate wastes
Digestion and absorption requires what two things
an intact and healthy GI epithelial lining that can resist the effects of its own digestive secretions
the presence of enzymes for the digestion and absorption of nutrients
Digestion and Absorption involves…
the movement of materials through the GI tract at a rate that facilitates absorption
Dumping
movement through the GI tract that is too fast to allow digestion and absorption
What are the sections of the digestive system
Upper part
middle portion
lower segment
fourth part - accessory organs
What does the upper part of the digestive system consist of and what does it do?
the mouth, esophagus and stomach
they act as an INTAKE source and receptacle through which food passes and in which INITIAL DIGESTIVE processes take place
What does the middle portion of the digestive system consist of and what does it do?
the small intestine: duodenum, jejunum, ileum
Most digestion and absorption processes occur here in the small intestine
What does the lower segment of the digestive system consist of and what does it do?
The cecum. colon, and rectum
Serves as a storage channel for the efficient elimination of waste and the large intestine allows for some fluid reabsorption
What is the fourth part of the digestive system and what does it do?
It is the accessory organs like the salivary gland, liver, and pancreas
They produce digestive enzymes that help dismantle food and regulate the use and storage of nutrients
What are the important anatomical portions of the mouth
Lips
Cheeks
Palate
Tongue
Teeth (Mastication)
Salivary Glands (Lubrication)
Muscles
Maxillary Bones
Saliva contains the enzyme ___ (___) that aids in digestion of ___
amylase (ptylain); starches
Esophagus
collapsible muscular tube (a transportation tube)
about 10 inches long
carries food from the pharynx to the stomach
What are the sections of the stomach?
the cardia, fundus, body, and pylorus
The Cardia
The portion of the stomach directly connected and closest to the esophagus
contains the cardiac opening
The Pyloris
The area at the bottom of the stomach closest to the duodenum of the small intestine
has the pyloric sphincter
Stomach Body and Fundus
the body is the largest mid portion while the fundus is the top portion above the level of the cardia or on the same level
Cardiac Opening
An opening into the stomach - not really a sphincter since stomach contents can get back out
opens and closes in the cardia
prevents reflux back into the esophagus
What is the pH of the esophagus compared to the stomach
esophagus pH of 8
stomach pH of 1-2
Pyloric Sphincter
sphincter near the end of the stomach leading to the duodenum
regulates the rate of stomach emptying into the small intestine
What does the stomach have that the esophagus does not which allows regeneration and protection from stomach acid
prostaglandins
Barret’s Esophagus
a condition of cellular change in the esophagus from stomach content reflux
What protects the stomach from enzymes and acids?
Gastric Mucosal Protection consisting of water soluble mucus and water insoluble mucus
Water Soluble Mucus
A gastric mucosal protection
It is washed from the mucosal surface and mixes with luminal contents
Its viscid nature makes it a lubricant to prevent MECHANICAL damage to the stomachs mucosal surface
Water Insoluble Mucus
A gastric mucosal protection
forms a thin and stable gel that adheres to the gastric mucosa surface
It gives protection from the proteolytic actions of pepsin
Forms an unstirred layer that traps bicarbonate thus forming an interface between the luminal contents of the stomach and its mucosal surface
What gastric mucosal protection form is more stable?
Insoluble
Small intestine
Duodenum –> Jejunum –> Ileum –> Cecum –> Colon (not part)
It is the major area of absorption of nutrients that is occurring
Duodenum
first part of the small intestine
contains the openings of the bile and pancreatic ducts
Jejeunum
second part of the small intestine
about 8 feet long
Ileum
the third part of the small intestine
about 12 feet long
terminates at the cecum
If there is a J tube or ileostomy bringing waste directly out of the small intestine, what would that look like and why?
It would be much more watery and loose since the large intestine is the one absorbing most of the water
Because of this the feces is more full of nutrients that are unabsorbed, electrolytes, and water that we need to monitor for with imbalances
Cecum
area where the small and large intestine meet
What quadrant is the cecum/where the small and large intestine meet?
Right Lower Quadrant
What is the GI wall structure like?
Inner Mucosal Layer
Submucosal Layer
Muscularis Layer with Circular and Longitudinal Muscle Layers
Outer serosal layer/Peritoneum
Inner Mucosal Layer
part of GI wall
cells produce mucus here that lubricates and protects the INNER surface of the alimentary canal
Submucosal Layer
part of GI wall
consists of connective tissues to keep GI sections where they belong
contains blood vessels, nerves, and structures responsible for secreting digestive enzymes
Muscularis Layer
part of GI wall
has a circular and longitudinal muscle layer
facilitates movement of the contents of the GI tract (peristalsis)
Outer Serosal Layer/Peritoneum
loosely attached layer to the outer wall of the intestine (the peritoneal layer attaching to abdomen wall)
Mucus is a ___ and ___
lubricator and protector
What is the layers of the GI tract from outermost to innermost?
Peritoneum –> longitudinal muscle –> circular muscle –> submucosal layer –> inner mucosal layer/mucous membrane –> lumen of the gut
Peritoneum
serous membrane lining the abdomen and the abdominal organs
Parietal Peritoneum
The serous membrane that lines the abdominal cavity
Lines the walls of the abdomen
Visceral Peritoneum
serous membrane that forms the mesentery (folds of the visceral peritoneum) which supports the intestines and blood supply
covers the abdominal organs
Peritoneal Fluids
several mL of fluid that moisten the surface of the peritoneal layers
The membranes are able to then glide smoothly over each other as the intestinal tract changes shape during digestion
Paracentesis
If someone has low plasma proteins, low oncotic pressure, or ascites/fluid build up from something like liver disease we can use a needle to remove some fluid
Where are the female reproductive parts located
in the peritoneal area
Where are the kidneys located
retroperitoneal (behind)
Disgestion
Process by which food is broken down mechanically and chemically in the GI to convert into an absorbable form
chewing + enzymes
What are some processes of digestion
hydrolysis
enzyme cleavage
fat emulsification
Absorption
uptake of water, FAs, monosaccharides, amino acids, vitamins and minerals from the lumen of the gut into the capillary networks and lacteals (lymph capillaries) of the villi
reusing the broken down parts
Absorption occurs primarily in the …
small intestine
Where does carbohydrate digestion start?
Digestions of starch begins in the mouth with amylase
Brush Border Enzymes
enzymes in the small intestine that convert disaccharides to monosaccharides
What breaks down fats?
gastric and pancreatic lipase
Bile Salts act as …
a carrier system
When does protein break down begin
in the stomach with the action of pepsin - it will then further break down via pancreatic enzymes
Pepsin is the reason what is important?
the mucosal protection of the layers of the stomach
What are some GI secretions that are important
Salivary (1200 mL)
Gastric (2000 mL)
Pancreatic (1200 mL)
Biliary (700 mL)
Intestinal (2000 mL)
total =7100 mL
What functions does saliva provide?
protection and lubrication and a mucus coating of food
antimicrobial action via lysozyme
initiation of digestion of starches via ptyalin and amylase
Mucus Secreting Cells are located…
throughout the stomach
Oxyntic (Gastric) Glands
located in the body and fundus of the stomach
These include parietal cells and chief cells
Parietal Cells
gastric cells that secrete HCl and intrinsic factor
Chief Cells
gastric cells that release pepsinogen for protein digestion
Pyloric Glands
glands found in the antrum that secrete mucus, some pepsinogen and gastrin in the stomach
Bile Salts
biliary product
it can emulsify and help in the absorption of fats and fat soluble vitamins
Fat Soluble Vitamisn
ADEK
Brunner’s Glands
intestinal glands
located where the stomach empties and secretes large amounts of alkaline mucus
protects the duodenum from acidic chyme and digestive enzymes
Crypts of Lieberkuhn
intestinal gland
secrete serous alkaline fluids
Peptidases
surface enzymes that aid in absorption in the small intestine
split amino acids
Disaccharidases
surface enzymes that aid in absorption in the small intestine
split sugars
Enzymes used in the digestion of carbohydrates
lactase
sucrase
amylase
maltase
alpha dextranase
The end product of the enzymes that convert carbohydrates via digestion is…
glucose (and maybe some other stuff)
Pancreatic Enzymes that break down proteins in the Small Intestine
Trypsin
Chymotrypsin
Carboxypeptidase
Elastase
The end product of the enzymes in the small intestine that convert proteins via digestion is…
always amino acids (maybe some other byproduct)
3 Levels of Control of Secretory Functions
Local
Humoral
Neural Influences
Local Control of Secretory functions
pH
Osmolality
Chyme
They act as stimuli for neural and humoral mechanisms
Neural Influences of Secretory Functions
Mediated with the ANS
Increased with parasympathetic stimulation
Inhibited with sympathetic activity
___ nervous system causes more digestion
parasympathetic
___ nervous system causes less digestion
Sympathetic
Autonomic Neural Control: Sympathetic
Controlled via spinal nerves
Inhibits smooth muscle contractions
Vasoconstriction occurs
The last two are why SNS stops digestion
Autonomic Neural control: Parasympathetic
Controlled via the vagus and pelvis nerves
Promotes smooth muscle contraction
Vasodilation occurs
Leads to secretion of enzymes like pepsin
What receptors and neurotransmitter help with PNS and peristaltic activity
muscarinic receptors and acetylcholine (helps increase peristalsis and vasodilation in the GI system)
What does the enteric/intrinsic system do for neural control of the GI system
it controls motility of GI smooth muscles and secretion of blood flow via stretch of the wall
Auerback’s (Mesenteric Plexus)
Enteric/Intrinsic
Located in the muscular layer and primarily controls motility of GI smooth muscle
Meissner’s (Submucosal Plexus)
enteric/intrinsic
located in the submucosa and primarily controls secretion and blood flow to GI region
Gastrointestinal Movements
Tonic Movements
Rhythmic Movements
Tonic Movements
continuous movements that last for minutes or even hours in the GI system
contractions occur AT SPHINCTERS
Rhythmic Movements
intermittent contractions responsible for mixing and moving food along the digestive tract
What kind of GI movements are peristaltic movements?
RHYTHMIC (propulsive) movements
Important GI Hormones
Cholecystokinin
Secretin
Gastrin
Cholecystokinin
stimulates contraction of the gall bladder (helps move bile)
Stimulates secretion of pancreatic enzymes
slows gastric emptying
Secretin
stimulates secretion of bicarbonate containing solution by pancreas and liver
Gastrin
stimulates secretion of gastric acid and pepsinogen
increases gastric blood flow
stimulates gastric smooth muscle contraction
stimulates growth of gastric, small intestine, and colon mucosa
Food must be ___ ___ and absorbed
broken down
What forms must carbohydrates be in for absorption
Monosaccharides (single sugars)
ex: Fructose - facilitated diffusion (no energy need)
ex: Glucose and galactose - Na dependent carrier system that requires ATP
What forms must fats be in for absorption
formation of MICELLES (action of bile salts) and transported to villi for absorption
Where does the absorption of fat primarily occur
in the upper jejunum
What are MCT and LCT and why is MCT better absorbed
they are middle and long chain triglycerides and it is easier to absorb the middle chain like coconut oil due to size
Water can follow ___ or ___
glucose or sodium
How big must proteins be for absorption?
1,2, or 3 amino acids long
How are proteins transported in absorption
by facilitated diffusion and ATP dependent sodium linked processes (no energy and energy)
Water in absorption is linked to absorption of osmotically active particles like…
glucose and sodium
Large Intestine
about 5 feet long
absorbs water and eliminates wastes
Manufactures vitamins including B vitamins and vitamin K
Pernicious Anemia
a megaloblastic macrocytic anemia
occurs without intrinsic factor from parietal cells
can be autoimmune
there is a neurologic deficit without B12 that takes time to manifest
Large intestine only secretes ___
mucus
What are the areas of the large intestine
Ascending Colon (right lower quadrant)
Transverse
Descending
Sigmoid
Rectum
Rectum
part of the large intestine
has valves and an internal and external sphincter
Ileocecal valve
valve in the rectum/large intestine that prevents contents of the large intestine from entering the ileum
Anal Sphincters
guard the anal canal
internal and external
we cannot see the internal but we can see the external
Internal Anal Sphincter
several CM long circular thickening of smooth muscle that lies inside the anus
cannot be viewed by use outside
External Anal Sphincter
composed of striated voluntary muscle surrounding the internal sphincter
Controlled by nerve fibers in the pudendal nerve (part of the somatic NS under voluntary control)
The largest gland in the body weight 3-4 pounds is the ___
liver
Kupffer’s Cells
tissue macrophages in the liver
remove bacteria in the portal venous blood
The liver is a ___
detoxifier
The liver will remove excess…
glucose and AA from portal blood
The liver synthesizes…
glucose, amino acids, and fats
The liver aids in the digestion of…
carbohydrates, proteins, and fat
The liver can do what 2 things to blood
store and filter it (200-400 mL of blood)
High First Pass
Metabolism
If a drug passes through the liver it will go from an active form to inactive
This may be why we do drugs IM IV or SQ
What, other than blood, can the liver store?
Vitamin A
Vitamin D
Vitamin B12
Iron
The liver secretes ___ the emulsify fats (500-1000 mL a day!)
Bile
What about the liver delays pernicious anemia
the fact it stores vitamin B12 there
The liver and gallbladder share …
common ducts
Hepatic means
liver
Renal means
kidney
What duct comes directly off the liver
Hepatic Duct
what duct comes directly off the gallbladder
the cystic duct
The hepatic duct and cystic duct merge into the…
common bile duct
The common bile duct and pancreatic duct merge into the …
ampulla of vater and sphincter of oddi
Where does the sphincter of oddi open up to
the duodenum
Location of a ___ determines what organ will be affected
block (ex: if the cystic duct is blocked only the gallbladder is effected)
The sphincter of oddi prevents..
reflux of intestinal contents into the common bile duct and pancreatic duct
What are not included in the secretions in the pancreatic duct?
insulin and glucagon
these go directly into the blood
Gallbladdar
stores and concentrates biles
can contract to force bile into the duodenum during fat digestion
How does the presence of fatty materials stimulate the release of bile
presence of fatty materials in duodenum stimulates cholecystokinin to release which leads to gall bladder contraction and relaxation of the sphincter of oddi
Exocrine
secreted into a duct
Endocrine
secreted into the blood
The pancreas as an exocrine gland does what
secretes sodium bicarbonate to neutralize the acidity of the stomach contents as they enter the duodenum
What is in pancreatic exocrine juices
pancreatic juices contain enzymes for digesting carbohydrates, fats, and proteins
The pancreas as an endocrine gland does what
Insulin secretion
Insulin secretion is produced by
the islets of langerhans cells in the pancreas
Insulin is secreted…
into the blood stream
Insulin is important for ___ metabolism
carbohydrate
Risk Factors for GI Disorders
Family Hx
Chronic laxative, alcohol, tobacco use
Chronic high stress levels
Allergic reactions to food or meds
Long term GI conditions like ulcerative colitis may predispose someone to colorectal cancer
Previous abdominal surgery or trauma leading to adhesions
Neuro disorders impairing movement, particularly with chewing or swallowing
Cardiac, respiratory, and endocrine disorders can lead to constipation
DM may predispose someone to oral candida infections
How does nicotine cause GI disorders
it stimulate muscarinic receptors and can lead to consipation
Adhesions
like scar tissue forming between the mucosa of the GI tract and wall of the abdomen leading to pleura or bowel pieces sticking together
What to look for on an abdominal assessment (in order)
Inspect - skin color, abnormalities, contour, tautness, distension
Auscultate - bowel sounds
Percuss - air or solids
Palpate - tenderness
Borborygmi
a rumbling or gurgling noise made by the movement of fluid and gas in the intestines
What needs to be done before percussion and palpation?
auscultation (in all 4 quadrants)
Normal bowel sounds occur ___ to __ times a minute or __ to ___ seconds
5 to 34 times
5-15 seconds
If you are not hearing any bowel sounds how long must you listen in each quadrant
5 minutes
Upper GI Barium Swallow
An examination of the upper GI tract under fluoroscopy performed after the client drinks barium sulfate
Requires fasting from foods and fluids overnight prior to the study
Post Barium Swallow what must the patient do?
drink 6-8 cups of water x2 days to pass the barium (since it can cause issues and constipation)
May need a laxative to help
What will stool look like when passing barium
chalky
Lower GI Barium Enema
A fluoroscopic and radiographic exam of the large intestine after rectal instillation of barium sulfate
May be done with or without air
Requires laxative evening prior and morning of procedure and liquid diet the day before the procedure
After a barium enema, what must be done
increase fluids or use a laxative to monitor for passage of the barium
Gastroscopy
Insertion of an endoscopic instrument through the esophagus into the stomach and upper portion of the small intestine to visualize the mucosal lining
look for lesions that need removal or wall ulceration
Important considerations for Gastroscopy
no fluids until gag reflex returns
after procedure monitor resp, cardiac, and neuro status
important to monitor VS before and after
What to monitor for after gastroscopy?
Monitor for signs of bleeding, as evidenced by hypotension, pallor, and tachycardia
Monitor for perforation as evidenced by pain, tachypnea, and rales
Sigmoidoscopy
Endoscopic visualization of the sigmoid colon using a sigmoidoscope
does not go far in but does need a clear GI tract to see
Sigmoidoscopy is invasive so…
it requires informed consent
What sort of diet should be done before a sigmoidoscopy
a full liquid diet and laxatives because they must have diarrhea and empty the GI tract for a clear sigmoid colon
What can be done following the sigmoidoscopy
Normal activities and diet may be resumed post procedure but notify provider if fever >101° F, difficulty breathing, stomach pain, or bright red rectal bleeding occurs
there is risk for perforation and infection
Colonoscopy
A fiberoptic endoscopic study in which the lining of the large intestine is visually examined
Requires informed consent - invasive
looks at entire colon
Preparation for colonoscopy
clear liquid diet
bowel preparation
*all to clear colon
Post procedure colonoscopy
client returns to normal activities and diet
monitor for signs of colon perforation, AEB abdominal pain or distention, malaise, fever, purulent rectal drainage, or lower GI bleeding
How must stool run before a colonoscopy
run clear or light yellow with no stool particles
Gallbladder Series
Oral cholecystography to study the dye-filled gallbladder by radiographic film
What is important to tell the client about regarding the dye for a gallbladder series?
Instruct client to go to the emergency department if a rash, itching or hives, or difficulty in breathing occurs after taking the tablets
the dye can be painful to micturate
What must be done before a gallbladder series
a low fat supper before the test then fasting after midnight the night prior
After a gallbladder series what sort of diet should be done
a high fat meal to help with dye elimination from the gall bladder
___ is common since gallbladder series dye is excreted in urine
Dysuria (painful or difficult urination)
Liver Biopsy
A needle is inserted through the abdominal wall to the liver to obtain a tissue sample for biopsy and microscopic examination
What to do pre procedure for a liver biopsy
Obtain informed consent
Assess hematological laboratory results
Administer sedative as prescribed
NPO after midnight on the day prior to the test
Note that the client is placed in the supine or left lateral position during the procedure
What to do post procedure for a liver biopsy
Assess vital signs frequently (every 15 minutes for an hour after)
Assess biopsy site for bleeding
Monitor for peritonitis
Maintain bedrest for 24 hours
Place client on the right side for 1 to 2 hours to decrease the risk of hemorrhage
The liver is on the __ side of the body
right
How big is the needle for a liver biopsy
14-18 gauge (huge and thick)
Liver biopsy comes with a huge risk for waht
bleeding since the liver is so vascularized - could cause bleeding all over the peritoneum
Why does the patient lie on the left side for the liver biopsy and then the right side after
to allow access to the liver during and then put pressure on the site afterward
Paracentesis
Transabdominal removal of fluid from the peritoneal cavity for the analysis of electrolytes, red blood cells and white blood cells, bacterial and viral cultures, and cytology studies
Obtain informed consent
What must be done prior to start of paracentesis
Void prior to the start of procedure to empty bladder and to move bladder out of the way of paracentesis needle
Measure abdominal girth, weight, and baseline vital signs
What position is the patient in during paracentesis
the client is positioned sitting on the edge of the bed with the back supported and the feet resting on a stool, or lying prone during the procedure
What to do post paracentesis
Monitor for hematuria due to bladder trauma
Instruct client to notify physician if the urine becomes bloody, pink, or red
Possibility to nick the bladder is why we watch for hematuria
Stool Specimens
Examination of stool for the presence of occult bleeding
What to do pre stool specimen procedure
Instruct client to avoid aspirin, NSAIDs, red meat, poultry, and fish for 3 days prior to the collection
These things can contribute to further occult bleeding or cause false positives
Occult Bleeding
bleeding that cannot be seen with the naked eye
goes on a specimen card in with a reagent and will light up blue if positive for occult blood
Liver and Pancreas Lab Studies can look at levels of what things
Alkaline Phosphatase
Prothrombin time (PT)
Serum Ammonia
Liver Enzymes (Transaminase Studies)
Cholesterol
Bilirubin
Amylase and Lipase
*these can alert us to liver damage
Alkaline Phosphatase
released during liver damage or biliary obstruction
high amount above 13-120 or 0.5-2.0 can indicate liver damage
Prothrombin time
prolonged PT time with liver damage (coagulation time)
above 12.5 seconds indicates damage
The increase in PT means a greater risk of bleeding d/t decreased clotting factors
Serum Ammonia
Assesses the ability of the liver to deaminate protein by products
if the liver cannot turn ammonia into urea, an increased ammonia amount means it is secondary to cirrhosis or hepatitis leading to confusion, sleepiness, hand tremors, or coma
What else could lead to a false high serum ammonia
high protein diet
Transaminase Studies (Liver Enzymes)
elevated levels with liver damage
AST, ALT, and LDH (Aspartate Aminotransferase, Alanine Aminotransferase, Lactic Dehydrogenase) levels increase
Cholesterol Studies
increase can indicate pancreatitis or biliary obstruction (normal value under 200 mg/dL)
Bilirubin Studies
increases indicate liver damage or biliary obstruction
can be direct, indirect, or total kind
comes from recycled heme during the breakdown of RBC
indirect is water soluble with direct fat soluble and we find indirect from the total and direct together
All liver and pancreas lab studies are done using __ blood
venous
Amylase and Lipase Studies
Elevations indicate pancreatitis / pancreas damage
S/S Common to GI Disorders
Anorexia
Nausea
vomiting or emesis
GI bleeding
What 2 ways can nausea be stimulated
unpleasant subjective sensation from stimulation of the vomiting center in the medulla
may be stimulated by duodenum distension
___ leads to nausea and vomiting
Hypoxia
Vomiting involves what areas of the brain to trigger
medulla vomiting center and the CTZ (chemoreceptor trigger zone)
What can act as neuromediators for vomiting
dopamine
serotonin
opioids
Vomiting serves a __ function
protective
*it forcefully expels contents that may harm you
Vomitus
Emesis = Vomiting
Hematemesis
blood in the vomitus
may be bright red or have a coffee ground appearance
Hematochezia
Passage of bright red blood in the stool
Usually indicates bleeding is from the lower bowel
Coating of stool with bright red blood is associated with hemorrhoids
always concerning/frightening
Bright red bleeding in the stool usually means bleeding comes from …
the lower bowel (or hemorrhoid)
Melena
Black tarry stool caused by digestion of blood in the GI tract
Usually indicates bleeding above ileocecal valve
May increase BUN due to absorption of nitrogenous end products from digestion of blood
The ileocecal valve is in what quadrant
the right lower quadrant
Melena indicates bleeding where
above the ileocecal valve- so small intestine and before
Occult Blood (Hidden) must be detected by and are usually caused by ?
Must be detected by chemical testing & usually caused by gastritis, peptic ulcer, or lesions of the small intestine
Swallowing mechanism
depends on the coordinated action of the tongue and pharynx
The tongue and pharynx (therefore swallowing) is innervated by what cranial nerves
V
IX
X
XII
Strictures
narrowing of the esophagus
What causes swallowing disorders or alterations in swallowing
altered nerve function or strictures
What are some swallowing issues?
Dysphagia
Odynophagia
Achalasia
Increased risk for aspiration!
Dysphagia
difficulty swallowing
Odynophagia
painful swallowing
Achalasia
lower esophageal sphincter fails to relax and food stays in the lower esophagus
painful
Esophageal Diverticulum
outpouching of the esophageal wall leading to retention of food
Common s/s of esophageal diverticulum
gurgling
belching
coughing
foul smelling breath
Mallory Weiss Syndrome
longitudinal tears in the esophagus
Infection here can lead to inflammatory ulcer or mediastinitis
What is Mallory Weiss Syndrome etiology associated with?
chronic alcoholism or severe retching or vomiting
Gastroesophageal Reflux (GERD)
Backward movement of gastric contents into the esophagus resulting in heartburn
Reflux of gastric contents results in irritation & erosion of the lower esophageal mucosa
GERD is thought to be associated with …
Thought to be associated with weak or incompetent lower esophageal sphincter that allows reflux to occur
What is NOT a good indicator of extent of mucosal injury in GERD?
severity of heartburn
GERD pain is ___ or ___ and may radiate to what areas?
epigastric or retrosternal
radiates to throat, shoulder, back
GERD can produce what S/S
respiratory symptoms like wheezing, chronic cough, hoarseness
chronic persistent reflux can cause strictures from scarring, spasms, and edema
Barret’s esophagus
Barrets esophagus can lead to ___ ___
esophageal cancer
GERD can be mistook for…
something more serious like a heart attack
Treatments for GERD
Avoiding large meals
Avoiding alcohol use and smoking
Eating meals sitting up
Avoiding recumbent position several hours after a meal
Avoiding bending for long periods
Sleeping with the head elevated
Losing weight if overweight
Sit up for several hours as well after meals
Avoid bending if overweight or have tight clothing
Major Causes of gastric irritation and ulcer formation
Aspiring or non steroidal anti inflammatory drugs (NSAIDS)
infection with H Pylori
also compounds with stress
How does NSAIDS cause gastric irritation and ulcer formation
irritates the gastric mucosa and inhibits prostaglandin synthesis (which allows the stomach to be attacked by its own secretions - prostaglandins release from damaged cells and cause fever and damage cell walls further usually but also help protect the stomach)
Why do H Pylori cause ulcer formation
they thrive in acidic environments like the stomach
disrupts the mucosal barrier that protects the stomach from harmful effects of its digestive enzymes
To avoid NSAID GI harm always do what
take them with food
Types of Gastritis
Acute
Chronic
Infective
Erosive
Acute Gastritis
A transient inflammation of the gastric mucosa
Most commonly associated with local irritants such as bacterial endotoxins, alcohol, and aspirin
Chronic Gastritis
Characterized by the absence of grossly visible erosions and the presence of chronic inflammatory changes
Leads eventually to atrophy of the glandular epithelium of the stomach
Caused by H pylori gastritis, autoimmune gastritis, multi focal atrophic gastritis, chemical gastropathy
What may cause erosive gastritis
person who ingested ASA and had an acute lesion
How to detect H Pylori infection
- C Urea Breath test using a radioactive carbon isotope
- stool antigen test
- endoscopic biopsy for urease testing
- blood tests to obtain serologic titers of H pylori antibodies
What does H Pylori produce that we can detect to diagnose infection
Urea
Peptic Ulcer Disease
An ulceration in the mucosal wall of stomach, pylorus, or duodenum in portions that are accessible to gastric secretions - holes in the stomach
Erosion may extend through the muscle to the peritoneum
The most common peptic ulcers are ___ and ___ ulcers
gastric and duodenal
Gastric Ulcers
Involves ulceration of the mucosal lining that extends to the submucosal layer of the stomach
sharp stomach ulcer
Predisposing Factors for Gastric Ulcers
stress
smoking
use of steroids
NSAIDS
alcohol
hx of gastritis
infection with H Pylori
What exactly is gastritis
a group of GI issues involving stomach lining inflammation
things seen on assessment of a gastric ulcer
gnawing sharp pain in or left of the mid epigastric region 1 to 2 hours after eating
nausea and vomiting
hematemesis
Duodenal Ulcers
a break in the mucosa of the duodenum
similar to gastric ulcer but a different pain pattern
Risk factors for Duodenal Ulcers
alcohol intake
smoking
stress
caffeine
use of ASA
corticosteroids
NSAIDS
H pylori infection
What is seen on assessment of Duodenal Ulcers
burning pain in the mid epigastric region area 2 to 4 hours after eating and during the night
pain that is often RELIEVED BY EATING
melena
Complications of Peptic Ulcers
- Hemorrhage (from granulation tissue or from erosion of an ulcer into an artery or vein)
- Obstruction (edema, spasm, contraction of scar tissue and interference with the free passage of gastric contents through the pylorus or areas nearby)
- Perforation (when an ulcer erodes through all the layers of the stomach or duodenum wall)
Risk factors for stress ulcers
Large surface-area burns
Trauma
Sepsis
Acute respiratory distress syndrome
Severe liver failure
Major surgical procedures
psychological stress
not just psych stress, but physical as well
Zollinger Ellison Syndrome
Highly malignant type of GI cancer caused by a gastrin secreting tumor (gastrinoma)
More than 2/3 are malignant
Where is the zollinger ellison syndrome tumor usually found?
in the pancreas but may be in the submucosa of the stomach or the duodenum
What may assessment of Zollinger Ellison Syndrome show
diarrhea
impaired fat digestion
elevated serum gastrin
decrease in intestinal pH
Gastric Cancer
abnormal malignant growth in the stomach
S/S of Gastric Cancer
Anorexia
Nausea and vomiting
Indigestion and epigastric discomfort
A sensation of pressure
Dysphagia
Weight loss
Palpable mass
Fatigue
Anemia
Ascites
Sensation of pressure is due to the growth
Risk factors for Gastric cancer
Genetic predisposition
Carcinogenic factors in the diet
Diet high in starch and salt and low in fresh, green leafy vegetables and fresh fruits
Smoking & alcohol
History of gastric ulcers
Presence of Helicobacter pylori
Autoimmune gastritis
Gastric adenomas or polyps
Gastric Polyp
abnormal growth on the lining inside the stomach
Vitamin B12 Deficiency Results from either..
- inadequate VB12 intake
- Lack of absorption of ingested VB12 from the intestinal tract
- not making intrinsic factors
- receptors for the complex cannot detect
S/S of Vitamin B12 Deficiency
Severe pallor
Fatigue
Weight loss
Smooth, beefy red tongue
Slight jaundice
Paresthesia of the hands and feet
Disturbances with gait and balance
One of the biggest concerns of VB12 deficiency is
neurological disorders
Dumping Syndrome
rapid emptying of the gastric contents into the small intestine
occurs following a gastric resection
tonic and rhythmic movements are supposed to keep it moving at the right rate but this stops them somewhat
S/S of Dumping Syndrome
Symptoms occurring 30 minutes after eating
Nausea and vomiting
Abdominal cramping
Feelings of fullness
Diarrhea
Palpitations
Tachycardia
Perspiration
Weakness and dizziness
Borborygmi
Altered Intestinal Function includes what things
Irritable bowel syndrome
Inflammatory bowel disease
Diverticulitis
Appendicitis
Alterations in bowel motility
Malabsorption syndrome
Cancer of the colon and rectum
Irritable Bowel Syndrome (IBS)
persistent or recurrent symptoms of abdominal pain
IBS S/S
altered bowel function
varying complains of flatulence and bloatedness
Nausea
anorexia
constipation
diarrhea (may be a ton in 2 hours)
anxiety or depression (can cause IBS or vice versa)
What treats both diarrhea and constipation and why?
FIBER
It can make diarrhea less watery and it adds bulk to move constipation
Inflammatory Bowel Diseases (IBDs)
Crohn’s Disease
Ulcerative Colitis
Chrohn’s Disease (regional enteritis)
IBD
a recurrent, granulomatous type of inflammatory response that can affect any area of the gastrointestinal tract from the mouth to the anus
can look like canker sores
if serious enough can cause need for colon resectioning/removal
Ulcerative Colitis
A nonspecific inflammatory condition of the colon
IBD
Where does Crohn’s Disease most likely occur
the terminal ileum
What does Crohn’s Disease often lead to
thickening and scarring
a narrowed lumen
fistulas
ulcerations
abscesses
Crohn’s Disease is characterized by __ and __
remissions and exacerbations
S/S of Crohn’s Disease
Fever
Cramplike pain after meals
Diarrhea semisolid and may contain mucus, pus, and blood
Abdominal distention
Anorexia, nausea, and vomiting
Weight loss
Anemia (poor iron and B1`2 absorption)
Dehydration
Electrolyte imbalances
Fistulas
communications from one part of the bowel to another or to another organ
Ulcerative Colitis
Ulcerative and inflammatory disease of the bowel results in poor absorption of nutrients
loss of elasticity and ability to absorb nutrients occur
What is the difference between ulcerative colitis and Crohns disease
UC is limited to the colon
Ulcerative colitis commonly begins in and spreads to?
begins in the rectum and spreads upward toward the cecum
What happens to the colon during ulcerative colitis
it becomes edematous and may develop bleeding lesions and ulcers
these ulcers may lead to perforation
what causes the loss of elasticity and ability to absorb nutrients in UC
scar tissue development
UC is characterized by ..
various periods of remissions and exacerbations
Acute UC results in…
vascular congestion
hemorrhage
edema
ulceration of the bowel mucosa
Chronic UC results in …
muscular hypertrophy
fat deposits
fibrous tissue
bowel thickening
shortening
narrowing
S/S of Ulcerative Colitis
Anorexia
Weight loss
Malaise
Abdominal tenderness and cramping
Severe diarrhea that may contain blood and mucus
Dehydration and electrolyte imbalances
Anemia
Vitamin K deficiency
Why is there Vit K deficiency in UC
it is impacting an area (colon) with a lot of the bacteria that make Vitamin K
What sort of areas are impacted with Crohn’s disease v UC
Crohns - anywhere along the small and large intestine
UC: more in the descending sigmoid colons and rectum
Crohns Disease takes on a ___ appearance from edema and inflammation
cobblestone
Ulcerative colitis is __ looking and in an ascending pattern
angry
Crohn’s Disease v Ulcerative Colitis: Location
CD - entire GI tract, sm. intestine and colon
UC: Limited to the colon
Crohn’s Disease v Ulcerative Colitis: Level of Penetration
CD: primarily submucosal
UC: primarily mucosal
Crohn’s Disease v Ulcerative Colitis: Rectal Involvement
CD: often spared
UC: almost always involved
Crohn’s Disease v Ulcerative Colitis: Hx
CD: abdominal pain, weight loss
UC: bloody diarrhea
Crohn’s Disease v Ulcerative Colitis: Colonoscopy
CD: skip lesions, cobblestone mucosa
UC: continuous involvement, pseudopolyps
Crohn’s Disease v Ulcerative Colitis: Complications
CD: bowel obstruction, fistulas, and strictures
UC: Colon cancer
What does skip lesions mean in Crohn’s Disease
areas of ulcer, healthy area, ulcer, health y area, etc (this isn’t in UC, that has continuous)
Why is Crohn’s disease more likely to have fistulas?
it goes through the surface and muscle layers so it can tunnel to different areas and the strictures can close off the openings that open up
Infections of the Intestine
Viral (rotavirus)
Bacterial (c difficile colitis, E coli)
Protozoal (E histolytica)
Diverticulosis
Outpouching or herniations of the intestinal mucosa
They can occur in any part of the intestine but are most common in the sigmoid colon
Diverticulitis
Inflammation of one or more diverticuli
Results when a diverticulum perforates, with local abscess formation
A perforated diverticulum can progress to intra-abdominal perforation with generalized peritonitis
S/S of Diverticulitis
Left lower quadrant abdominal pain that increases with coughing, straining, or lifting
Elevated temperature
Nausea and vomiting
Flatulence
Cramplike pain
Abdominal distention and tenderness
Palpable, tender rectal mass
Blood in stools
Slight fever
Elevated WBC count
The sigmoid colon is in what quadrant
Left lower quadrant
Hemorrhoids
dilated varicose veins of the anal canal
Hemorrhoids can be ___ ___ or ___
internal external or prolapsed
Internal Hemorrhoids lie where?
above the anal sphincter and cannot be seen upon inspection of the perianal area
External hemorrhoids lie where?
below the anal sphincter and can be seen on inspection of the perianal area
Prolapsed hemorrhoids can become…
thrombosed or inflamed
What can cause hemorrhoids?
portal HTN
straining
irritation
increased venous or abdominal pressure
labor and delivery
pressures on the body in jobs like carpentry
How does portal HTN cause hemorrhoids
you get a nodular liver and blood backs up since it cannot get through and it backs up into the intestines and causes esophageal varices and hemorrhoids
S/S of Hemorrhoids
bright red rectal bleeding
rectal mucus discharge
pain associated with thrombosis
rectal itching
Appendicitis
inflammation of the appendix
when the appendix becomes inflamed or infected rupture may occur within a matter of hours leading to peritonitis or sepsis
S/S and Assessment of Appendicitis
Pain in periumbilical area that descends to the right lower quadrant
Abdominal pain that is most intense at McBurney’s point
Rebound tenderness and abdominal rigidity
Low-grade fever
Elevated WBC count
Anorexia, nausea, and vomiting
Client in side-lying position with abdominal guarding
and legs flexed
Constipation or diarrhea
Pain from appendicitis occurs in what quadrant
Right lower quadrant
Appendicitis is most intense at ___point
McBurney’s
Peritonitis
inflammation of the peritoneum
infection of lining and can be life threatening
S/S of Peritonitis
Increased fever and chills
Progressive abdominal distention and abdominal pain
Right guarding of abdomen
Tachycardia and tachypnea
Pallor
Restlessness
Types of Diarrhea
- Large volume (osmotic and secretory - OS)
- Small volume (inflammatory bowel disease, infectious disease, irritable colon - iii)
We normally have how much stool a day?
150 g/day
Diarrhea
an increase in volume of stool
often it is an increase in stool fluid content and frequency
What are the 4 basic pathophysiologic causes of Diarrhea
- Increased secretion of electrolytes and water in bowel lumen (INCREASED SECRETION)
- Increased osmotic load within the intestine –> water retention in the bowel lumen (INCREASED OSMOTIC LOAD)
- Inflammation –> exudation of protein and fluid from intestinal mucosa (INFLAMMATION)
- altered intestinal motility –> rapid transit times (ALTERED INTESTINAL MOTILITY)
What things can cause increased secretion leading to diarrhea?
Cholera toxin
Clostridium endotoxin
Non-invasive microbial gastroenteritis
Carcinoid syndrome
Vasoactive intestinal peptide-secreting tumor
Villous adenoma
What things can cause increased osmotic load leading to diarrhea?
Sorbitol ingestion “sugar-free candy diarrhea”
Bile salt malabsorption
Lactase deficiency “lactose intolerance”
Malabsorption – celiac sprue
Post-antrectomy rapid gastric emptying “dumping syndrome”
Magnesium containing laxatives
Sorbitol
an ingredient in sugar free candy that can cause increased osmotic load and cause diarrhea
What can cause the inflammation leading to diarrhea?
Ulcerative colitis
Crohn’s disease
Radiation-induced enteritis
Invasive microbial gastroenteritis
What can cause the altered intestinal motility leading to diarrhea
Thyrotoxicosis
Irritable bowel syndrome
Neurologic disease (enteropathy in DM)
things to gather during the Hx for Diarrhea
- Is it acute or chronic
- What is the nature of stool: watery (secretory), bulky and greasy (osmotic), blood w or w/o leukocytes (inflammatory)
- Medications (antibiotics, laxatives, antihypertensive, anti inflammatory, diuretics)
- Other things like fever, abdominal pain, flatulence, extraintestinal sx like arthritis rashes weight loss and edema, and association with meals or fasting
What does secretory caused diarrhea look like
watery
what does osmotic caused diarrhea look like
bulky and greasy
What does inflammatory caused diarrhea look like
bloody with or without leukocytes
What to check on physical exam for diarrhea?
Degree of hydration
Presence of abdominal tenderness
Rectal mass or blood
Character of bowel sounds
Indicate –> etiology & severity of illness
Common Causes of Constipation
Failure to respond to the urge to defecate
Inadequate fiber in the diet (to add water to stool)
Inadequate fluid intake
Weakness of the abdominal muscles
Inactivity and bed rest
Pregnancy
Hemorrhoids
Mechanical Bowel Obstruction Issues
Adhesions
Intussusception
Volvulus
Incarcerated Inguinal Hernia
Adhesions
parts of the bowel fuse together
Intussusception
When the bowel slips on to itself
Volvulus
bowel twists
Incarcerated Inguinal Hernia
when intestine descends through area tested go through and it gets pinched off and lacks of blood supply
Intestinal Obstruction can be caused by what:
mechanical obstruction
paralytic ileus
abdominal distention
loss of fluids and electrolytes (hypokalemia)
Paralytic Ileus
intestinal obstruction
neurogenic or muscular impairment
often occurs after abdominal surgery
What can cause abdominal distention leading to intestinal obstruction
Gases (swallowed air) and fluids
Distention moves proximally
Intestinal Obstruction can lead to what
strangulation
gangrenous changes
perforation of the bowel
Intestinal Obstruction increases… leading to…
increases pressure leading to compromises of blood flow and leads to necrosis
Assessment of Intestinal Obstruction may show S/S like…
Pain
Absolute constipation
Abdominal distention
Vomiting
Borborygmi
Visible peristalsis
Extreme restlessness, weakness, perspiration, anxiety
Risk factors for Paralytic Ileus
physical manipulation of the bowel
Hypokalemia (potassium needed for good GI function)
they have not eaten well
neuro or muscular impairment
common after abdominal surgery to check for bowel sounds
If there is intestinal obstruction, then what may happen?
- the need for surgery
- need to have something come out someway, even vomiting
Causes for Peritonitis
Perforated peptic ulcer
Ruptured appendix
Perforated diverticulum
Gangrenous bowel
Pelvic inflammatory disease
Gangrenous gallbladder
Abdominal trauma and wounds
Celiac Disease
Immune-mediated disorder triggered by ingestion of gluten-containing grains (wheat, barley, rye)
Inappropriate T-cell response in genetically predisposed individuals
May impair absorption of macro- & micro-nutrients
may need blood test
The gall bladder is in what quadrant
upper right quadrant
Classic Form of Celiac Diseas presents in ___ and manifests as…
infancy
presents as: FTF, diarrhea, abdominal distention, occasionally severe malnutrition
Symptoms of Intestinal malabsorption
Diarrhea or constipation
Steatorrhea
Flatulence
Bloating
Abdominal pain
Belching
Cramps
Weakness, muscle wasting
Weight loss and abdominal distention
Intestinal Tumors
Malignant lesions that develop in the cells lining the bowel wall or develop as polyps in the colon or rectum
Colonoscopies can detect these
Complications of intestinal tumors include…
Complications include bowel perforation with peritonitis, abscess and/or fistula formation, frank hemorrhage, and complete intestinal obstruction
Metastasis of Intestinal tumors occurs via…
the circulatory or lymphatic system or by direct extension to other areas in the colon or other organs
The intestinal tract is very vascular and deeply involves with..
the lymph system (Peyers Patches) and nodes
S/S of Intestinal Tumor
Blood in stools
Abnormal stools
Anorexia, vomiting, weight loss
Malaise
Anemia
Ascending colon tumor: diarrhea
Descending colon tumor: constipation or some diarrhea, or flat ribbon-shaped stool due to a partial obstruction
Rectal tumor: alternating constipation and diarrhea
Guarding or abdominal distention
Abdominal mass (a late sign)
Cachexia (a late sign)
Ribbon stools indicate ___
obstruction
Cachexia
wasting syndrome
with decreased weight muscle atrophy fatigue weakness and very little appetite
Colorectal cancer is __ in cancer incidence and __ in cancer morality
3rd in incidence and 2nd in mortality
Etiology of Colorectal Cancer
Most arise from pre-existing benign adenomatous polyps that undergo sequential malignant transformation (only ~5% develop into cancer)
Adenomas
factors associated w malignant transformation (DNA damage, ras oncogene, inactivation of tumor suppressor gene, increasing size and histology)
the deeper it is the worse it is
Adenomas
neoplastic lesions of glandular epithelium that display abnormal cellular differentiation & are of varying architecture, sizes & shapes
(tubular, tubulovillous, villous)
If colorectal cancer is confined to the mucosa,,,
it is in situ (but it can progress to submucosa, muscularis propria and adjacent tissue - metastasis)
Colorectal cancer that is invasive …
can spread to regional lymph nodes and distance sites
Recurrence of rectal cancer is more common…
after re-sectioning
Risk Factors for Colorectal cancer
Hx of adenomatous polyps
familial disorders (familial polyposis)
personal hx of another malignancy or cancer
family hx of colon cancer in a first degree relative
diet and lifestyle
Diet and Lifestyle risk factors for colo rectal cancer
High animal fat consumption (red meat)
Low fiber consumption (lack of fruits & veggies)
Obesity
Ethanol
Refined sugar
Cigarette smoking
What are the benefits and downfalls of ASA in the GI system
It can lower incidence of colorectal cancer (and heart attack) but increases risk for GI bleed (NOT A CURE FOR CANCER THO)
What things can be seen on H&P of colorectal cancer
Asymptomatic - but Sx in advanced disease occur
There are few px specific findings
mass may be found on external palpation of the abdomen or on DRE but that is uncommon
What are some advanced disease symptoms in colorectal cancer
GI bleeding (occult, anemia)
Change in bowel habits (narrow caliber stool, chronic diarrhea, constipation)
Abdominal pain
Anorexia and weight loss (late)
Colorectal cancer is often considered a…
silent killer
Screenings for Colorectal Cancer
Stool occult blood tests
Digital rectal examination
X ray studies using barium (ex: barium enema)
Flexible sigmoidoscopy and colonoscopy
May need a barium enema, and regular sigmoidoscopy and colonoscopies at a younger age
