Mometrix Study Cards

Question 1

Discuss patient advocacy in gastroenterology nursing

Answer 1

Patient advocacy in gastroenterology includes:
1. Working for the best interests of the patient when an ethical issue arises, despite personal values that might be in conflict
2. Educating patients about their rights and responsibilities
3. Incorporating patients’ values into that plan of care
4. Assisting patients and families with resources to make difficult or complex decisions
5. Empowering patients to make decisions
6. Reporting abusive or negligent care and ensuring patient safety
7. Sharing patients’ concerns with physicians and other health providers
8. Collaborating with patients in the development of the plan of care
9. Showing respect for the patients and their families
10. Supporting cultural preferences and beliefs
11. Ensuring that patients have adequate knowledge to provide informed consent
12. Engaging in research to promote evidence-based practice
13. Lobbying for improved quality of patient care at the local, state and national levels
14. Providing follow-up care
15. Promoting routine screening such as for colon cancer

Question 2

Discuss the responsibilities of managing the gastroenterology department

Answer 2

There are five functions involved in managing the gastroenterology department: planning, organizing, directing, controlling and staffing
1. The manager of the gastroenterology department must consider resources, budgets, personnel and educational goals for the unit. The manager should confer with the staff in formulating any plans. Additionally, the manager must make informed decisions

2. Organizational practices can vary. The goal is to foster effective operations in the gastroenterology department
3. The manager should then direct the unit to accomplish the goals set by motivating and leading the staff
4. Control measures are established to foster the continued efficacy of the program. This entails setting clear standards, evaluating the process for efficacy, instituting improvements where needed, and staffing the unit

Question 3

Discuss the development of the field of gastroenterology nursing

Answer 3

1. The practice of nursing has been in existence for centuries. As medicine has advanced, so has nursing. This has led to the specialization; health care providers direct their practice to treating one organ system. Gastroenterology nursing has become specialized, in parallel with the field of gastroenterology
2. With the introduction of the semi-flexible scope by Rudolf Schindler, the gastroenterology field has grown tremendously. The need for nurses trained in the field has also mushroomed, ultimately leading to the practice of gastroenterology nursing
3. To develop standards of practice and goals for gastroenterology nursing field, the Society of Gastrointestinal Assistants was formed in 1974. That group evolved into the Society of Gastroenterology Nurses and Associates, Inc or SGNA

Question 4

Discuss the basic responsibilities of the gastroenterology nurse

Answer 4

1. The SGNA is responsible for outlining the practice and standards of gastroenterology nursing. This organization establishes standards that should be practiced to provide adequate care for the patient
2. The care givers must address patient needs first. Nurses must ascertain medical history, comfort levels, psychological concerns and educational needs. During any treatment or intervention, the patient must be monitored for safety and comfort. During follow up, the patient needs to be monitored for appropriate response and recovery
3. The gastroenterology nurse must be familiar with all equipment used. They need to be able to evaluate the instrument for problems, to assist in diagnostic or therapeutic procedures
4. Documentation of events, medications and outcomes need to be done
5. Maintaining and sharing knowledge is the responsibility of all members of the gastroenterology team

Question 5

Discuss the standards that concern they gastroenterology nurse

Answer 5

1. SGNA has established standards for the outcome of the practice of gastroenterology nursing. Standards offer guides to assess practice and outcomes in the field. The standards addressed are quality of care, performance appraisal, education, collegiality, ethics, collaboration, research, and resource utilization
2. The Joint Commission has also established standards to ensure safety and quality. For a department to be certified by the Joint Commission, the department must demonstrate its ability to meet Joint Commission standards, such as infection control
3. Other standards must be met, as well. Different regulatory agencies demand that certain specifics be met to ensure the safety of patients and of personnel. These agencies include the Centers for Disease Control and Prevention, the Environmental Protection Agency, the Food and Drug Administration, and the Occupational Safety and Health Administration

Question 6

Discuss the research process in gastroenterology nursing

Answer 6

Gastroenterology nursing research allows for improving outcomes, procedures and practices in gastroenterology nursing. Once a problem solution. This entails reviewing the knowledge available via literature and studies, formulating a hypothesis, setting up a study protocol, establishing measurement criteria for the data, collecting the data, analyzing the data and sharing conclusions

Question 7

Define the following elements of research: Variable, independent variable, dependent variable, hypothesis, sample, experimental group and control group

Answer 7

1. Variable is an entity that can be different within a population
2. Independent variable is the variable that the researchers change to evaluate its effect
3. Dependent variable is the variable that may be changed by alterations in the independent variable
4. Hypothesis is the proposed explanation to describe an expected outcome in a study
5. Sample is the selected population to be studied
6. The experimental group is that population within the sample that undergoes the treatment or intervention
7. The control group is that population within the sample that is not exposed to the treatment of intervention being evaluated

Question 8

Discuss the purpose of the nursing assessment

Answer 8

1. Nursing assessment evaluates patient data to help in diagnosis and treatment. The nurse assesses baseline health and medical history to be sure the patient will be safe. The nurse also determines what limitations the patient may have in terms of understanding or cooperation
2. Nursing assessment is an ongoing process, which includes baseline information, information on the patient’s response and recovery to the intervention and continued efforts to maintain the patients health
3. The nurse can collaborate with other team members to help in this assessment

Question 9

Discuss the purpose of nursing diagnosis and planning

Answer 9

1. Nursing diagnosis is directed at patient comfort and outcome. Nurses establish nursing interventions that are needed for the patient to be safe and comfortable. The nurse uses the diagnosis to direct therapies and to anticipate potentially needed interventions
2. Planning allows the nurse to outline the methods needed to achieve patient goals. This accounts for alternative therapies that may be needed, setting priorities, satisfactory outcomes to be achieved, and expectations for discharge.
3. The gastroenterology nurse needs to document the plan. The plan outlines nursing responsibilities, possible interventions, and expected outcomes

Question 10

Discuss the implementation of the nursing plan

Answer 10

1. Implementing the nursing plant requires a measure of fluidity. The original plan is based on initial data. As new data is accumulated, however, the original plan may be modified. There is a need to incorporate individual needs of the patient as the plan proceeds. Different interventions may be called for depending on individual responses or limitations. The nurse needs to continually monitor the patient’s response and status to be able to offer appropriate nursing interventions
2. Documentation is essential at every step of the way. The information can be useful in further treatment of the individual. It can also be used to assess the process so that improvements or adjustments can be made. The documentation may also be used for research purposes to further the knowledge of gastroenterology practice. The record may become necessary for legal purposes, as well

Question 11

Discuss the evaluation process in nursing care

Answer 11

1. In order to provide the best care for the patient, the nurse must evaluate the process in effect. This entails reviewing procedures and interventions in relation to standards of care, quality of care, and patient outcomes. Critical evaluation of the nursing process can lead to changes that may improve the quality of care for patients and/or identify personnel issues that need to be addressed. Modifying care plans is important to maintaining effective patient care. Deficiencies may be noted and can, therefore, be addressed
2. This underscores the importance of adequate documentation. In order to evaluate the process, the nurse must have access to the documentation to assess the present process. This evaluation may lead to changes that improve the quality of care in the gastroenterology department.

Question 12

Discuss the assessment of the cultural elements of wellness

Answer 12

A cultural assessment can begin by asking the patient with which cultural group the patient most identifies and by careful observation of patient responses and interactions. The Giger and Davidhizar’s Transcultural Assessment Model can serve as a guide. Element’s include:

1. Cultural: The country in which the person was born; their ethnicity; how long the person has lived in this country if born outside the US
2. Biologic: Color of skin and hair, body structure, ethnic-specific disorders, dietary preferences, psychological characteristics
3. Environmental: Cultural health practices and values, perceptions of health/sickness
4. Time: Perceptions of time, wok and social time. Past (focus on maintaining traditions), present (focus on here and now avoids planning), or future orientation (focus on future goals)
5. Social: Roles of culture, family, ethnicity, religion, work, friends, types of leisure activities
6. Special: Proxemics, body language
7. Communicative: Language abilities and preferences, voice quality, nonverbal language (gestures, eye contact), pronunciation/ enunciation

Question 13

Discuss assessment of the psychosocial elements of wellness

Answer 13

A psychosocial assessment should provide additional information to the physical assessment to guide the patient’s plan of care and should include:
1. Previous hospitalizations and experience with healthcare
2. Psychiatric history: Suicidal ideation, psychiatric disorders, family psychiatric history, history of violence and/or self-mutilation
3. Chief complaint: Patient’s perception
4. Complementary therapies: Acupuncture, visualization, meditation
5. Occupation and educational background: Employment, retirement and special skills
6. Social patterns: Family and friends, living situation, typical activities, support system
7. Sexual patterns: Orientation, problems, and sex practices
8. Interests/abilities: Hobbies and sports
9. Current or past substance abuse: Type, frequency, drinking pattern, use of recreation drugs, and overuse of prescription drugs
10. Ability to cope: Stress reduction techniques
11. Physical, sexual, emotional, and financial abuse: Older adults are especially vulnerable to abuse and may be reluctant to disclose our of shame or fear
12. Spiritual/Cultural assessment: Religious/Spiritual importance, practices, restrictions (such as blood products or foods), and impact on health/health decisions

Question 14

Discuss the assessment of the spiritual elements of wellness

Answer 14

Hope is a simple mnemonic used as a guideline for the spiritual assessment:
1. Hope - what sources of hope (who or what) do you have to turn to?
2. Organized - Are you a part of an organized religion or faith group? What do you gain from membership in this group>
3. Personal - What spiritual practices (prayer, meditation) are most helpful?
4. Effects - What effects do your beliefs play on any medical care or end-of-life issues and decisions? Do you have any beleifs that may affect the type of care the health care team can provide you with?

FICA is another abbreviated spiritual assessment tool:
1. Faith - Do you have a faith or belief system that gives your life meaning?
2. Importance - What importance does your faith have in your daily life?
3. Community - Do you participate and gain support from a faith community?
4. Address - What faith issues would you like me to address in your care?

Question 15

Discuss the importance of a pharmacology assessment upon patient admission for a procedure

Answer 15

A pharmacology assessment is especially important upon patient admission for a procedure because some medications may interfere with testing and others may increase the risk of complications. Patients should be advised to bring all current medications with them for the procedure so they can be examined as patients are not always good reporters and may overlook some medications if simply asked to list them. Assessment should include questions about what the patient was advised to do about medications the day of the procedure and whether the patient followed those directions, what prescriptions, OTC, supplements, and herbal preparations the patient normally takes as well as their dosages and when the last dose of each was taken. The patient should also be asked about any allergies the patient has, especially to any drugs or to latex, and what type of adverse reactions the patient has experienced

Question 16

Discuss hoe the following medications can impact gastroenterology procedures: Prescription medications, OTC medications, supplements and herbals

Answer 16

Some medications, supplements and herbal preparations can impact gastroenterology procedures:

1. Prescription medications: Blood thinners are of special concern because of increased risk of bleeding. For low-risk procedures, anti-platelet agents, warfarin, and novel oral anticoagulants are generally continued, but for high-risk procedures, medications may be withheld for 5 to 7 days prior to the procedure. Insulin is usually administered with a half-dosage prior to the procedure and half with a post-procedure meal. Oral anti-diabetics agents are usually withheld the day of the procedure until after completion
2. OTC medications: Because of increased risk of bleeding and interference with visualization, aspirin products and Pepto-Bismol are generally withheld for 7 days prior to the GI procedures and NSAIDs for 5 days. Antacids are withheld the day of the procedure. All other OTC medications should be withheld for 5 days
3. Supplements: Preparations that include iron are usually withheld for 7 days prior to a procedure
4. Herbals: Gingko increases the risk of bleeding, especially if patients also take other blood-thinning drugs and should be discontinued for 5 to 7 days prior to a procedure

Question 17

Describe a cross section of the esophagus

Answer 17

1. The inner lining of the esophagus is composed of squamous epithelium that abuts connective tissue called the lamina propria
2. The middle layer or submucosa consists of fibrous and connective tissue with nerves and blood vessels. It is separated from the lamina propria by a smooth muscle band called the muscularis mucosae
3. The muscularis layer is the outside tissue that has a layer of circular muscles followed by a layer of longitudinal muscle fibers. The Auerbach’s nerve plexus lies between these muscle layers
4. At the upper portion of the esophagus, there is a small area of striated muscle. The lower half of the esophagus has smooth muscle. There is a transition from striated muscle, which accounts for the first 5% of esophageal muscle, to the approximately 50% distal end composed of smooth muscle

Question 18

Describe Gastroesophageal Reflux Disease (GERD), its symptoms and its diagnosis

Answer 18

1. GERD is caused by reflux of gastric contents into the esophagus. Although some reflux is normal, when the reflux causes symptoms it is considered abnormal. The reflux of the acidic contents of the stomach into the esophagus causes an inflammatory reaction in the esophageal mucosa. Long term reflux can lead to Barrett’s esophagus in which the normal mucosal cells are replaced by columnar epithelium.
2. Patients complain of heartburn, dysphagia, and chest pain. Some may have coughing or wheezing if reflux contents are aspirated

Question 19

Discuss how GERD is diagnosed

Answer 19

Diagnosis of GERD can be made several ways
1. A barium swallow entails taking x-rays of swallowed barium as it passes through the esophagus. This can determine if there is an obstruction or other abnormality

2. Endoscopy can also be done, allowing for visualization of the lining of the esophagus, looking for abnormalities, masses, or inflammation. This procedure can also obtain a biopsy for tissue

Other tests may be indicated
1. Manometry is a test to measure muscle coordination and esophageal pressures. This may help to diagnose a motility disorder

2. A 24-hour pH study can determine the rate and time of reflux episodes and how these episodes may be related to other symptoms such as cough
3. Another test for correlating non-gastrointestinal symptoms with reflux is gastric emptying studies, which trace the path of a radioactive isotope that is swallowed by the patient

Question 20

Discuss the complications of and treatment for GERD

Answer 20

1. 50% of GERD patients develop esophagitis. Other complications include stricture formation, esophageal ulcerations, Barrett’s esophagus, gastrointestinal bleeding and aspiration pneumonia
2. To treat GERD, patients need to modify their diet to avoid things that may increase symptoms, such as coffee and alcohol. They must also attempt to lose weight if indicated. Other actions include avoiding lying down after eating for several hours and elevating the head during sleep
3. There are medications that may help with symptoms. These include antacids, H2 blockers, or proton pump inhibitors. Sometimes a motility agent is added to the regimen, such as Bethanechol or raglan
4. For those refractory to treatment, surgery can be done

Question 21

Discuss esophageal cancer

Answer 21

1. Esophageal cancer is usually squamous cell in origin. There are a smaller number of adenocarcinomas that develop in individuals with Barrett’s esophagus. Cancers of the esophagus are associated with chronic esophagitis, GERD, or tobacco and alcohol use.
   Patients present with dysphagia, odynophagia, weight loss and anorexia
2. Diagnosis can be made by Esophagogastroduodenoscopy or EGD, which permits visualization and an opportunity for tissue biopsy. Patients need to be evaluated for metastatic disease
3. Treatment is limited. Surgery can be done to alleviate symptoms. A stent can also be placed via EGD for obstructive symptoms. Despite treatment, the prognosis is poor, with a five-year survival rate of less than 5%

Question 22

Discuss the causes and symptoms of esophageal varices

Answer 22

1. Esophageal varices are the result of portal hypertension due to cirrhosis or other diseases impinging on the portal circulation. Submucosal vessels in the distal part of the esophagus become enlarged because of increased pressure from the portal system
2. Varices may be asymptomatic, but they are at risk for sudden disruption and massive bleeding. This can be life-threatening, requiring emergency intervention. Patients may present with blood coming from the mouth, or they may be in hypovolemic shock
3. Diagnosis can be made endoscopically. All supportive measures need to be taken to care for the patient, including cardiovascular support and replacement of blood products

Question 23

Outline the treatment of bleeding esophageal varices

Answer 23

1. Treatment for esophageal varices depends on the clinical state of the patient. To manage acute situations, commonly esophageal sclerotherapy is performed. This entails use of an endoscope to inject sclerosing substances into the bleeding varices. Complications of this procedure include perforation, ulcerations and stricture formations.
2. More recently, therapy for bleeding varices has included esophageal variceal ligation. Via the endoscope, bands are placed around the varices.
3. Some esophageal variceal bleeding requires the use of esophageal tamponade. This is accomplished by introducing a balloon device to be inflated against the varices
4. Preventative therapy to reduce the risk of another bleeding episode calls for consideration of a portal venous shunt to relieve the pressure of the portal hypertension. This procedure is not suited to emergency situations, however, since it is a difficult procedure with high morbidity and mortality. A newer, non-surgical treatment is being favored, Transjugular intrahepatic portosystemic shunt or TIPS

Question 24

Discuss the symptoms and treatment of esophageal strictures.

Answer 24

1. Esophageal strictures, abnormal collections of fibrous tissue, can interfere with the passage of nutrients to the stomach. Strictures can be the result of infection, esophagitis, or caustic injuries. Patients commonly present with progressive dysphagia
2. Treatment requires reducing the stricture to relieve interference. The patient is treated by using different forms of dilators, such as balloons or plastics. This compresses the stricture, opening up the esophageal lumen. Often these patients will require repeat dilation procedures for recurrent symptoms
3. Children may require surgery because they often have strictures that are long
4. The most common complication of dilatation is perforation

Question 25

Discuss removal of foreign bodies from the esophagus

Answer 25

1. Esophageal foreign bodies may be acute or chronic. The nature of the foreign body dictates the treatment. Endoscopy using a snare can be employed to extract the object. If applicable, it can also be crushed so that it can pass into the stomach. Sometimes, in adults, medications can be used to relax the LES so that the substance can more easily continue into the stomach. Surgery must be considered for certain objects, such as illegal drugs or sharp objects. It also needs to be considered when there are complications like bleeding or perforation
2. Possible complications of ingested foreign objects include perforation, bleeding, or local irritation

Question 26

Discuss caustic injury to the esophagus

Answer 26

1. Caustic injury can be caused by both alkaline and acidic toxins, but alkaline exposures are usually more harmful. Patients complain of pain and difficulty swallowing
2. Diagnosis requires evaluation for infection and/or perforation. An endoscopy is needed to assess the injury, but may be delayed since injuries may not appear immediately. Great care needs to be exercised to avoid perforation to the damage area.
3. Treatment varies, depending on the toxin. All patients must remain NPO, and a nasogastric tube should be placed. Subsequent complications may include strictures, which will need appropriate therapy. Some individuals are increased risk of cancer

Question 27

Discuss some infections of the esophagus

Answer 27

1. Infections of the esophagus are much more likely to occur in people who are immunocompromised. The most common are Candida, here’s simplex, and cytomegalovirus or CMV
2. Patients present with dysphagia and odynophagia. With severe infection, nerves can be compromised leading to dysfunctional motility. Rarely, infection can result in perforation. Because these individuals suffer from underlying medical conditions that make them susceptible, the infections can become systemic
3. Definitive diagnoses requires endoscopy, which visualizes the mucosal surface and allows for tissue collection
4. With Candida, the first line of treatment is nystatin therapy. If infection persists or is severe, the patient can be given Ketoconazole or amphotericin B. The viral infections are less likely to respond to curative treatment, but palliative treatment may help with symptoms

Question 28

Discuss achalasia

Answer 28

1. Motility disorders cause disruption of the normal peristaltic motion of the esophagus, and may involve the LES. These disorders include achalasia, diffuse esophageal spasm and nutcracker esophagus. Achalasia is the result of disrupted peristalsis and increased LES pressure
2. Symptoms of achalasia include dysphagia, regurgitation and weigh loss. On Barium x-ray, the esophagus is dilated and ends sharply at the LES junction
3. Treatment includes eating slowly and concomitantly drinking fluids. Dilatation of the esophagus can be helpful. Some may need surgery, however. Those who are not surgical candidates can get some relief with nitrates or calcium channel blockers. Recently, there has been good success with injecting botulinum toxin into the LES
4. Long term, patients may suffer from esophagitis, aspiration pneumonia and an increased risk of cancer

Question 29

Discuss Barrett’s esophagus

Answer 29

1. Barrett’s esophagus is the replacement of normal squamous epithelium by columnar epithelium. It is commonly associated with chronic reflux disease
2. Symptoms include those expected in reflux disease, such as heartburn, regurgitation and pain
3. Diagnosis requires an endoscopy to visualize the surface and obtain tissue. The reddish columnar epithelium can be seen jutting above the gastro-esophageal junction
4. Treatment is to relieve symptoms. The risk of cancer is increased in these patients. Therefore, the individual diagnosed with Barrett’s esophagus should be regularly evaluated for progression of disease

Question 30

Describe the function and gross anatomy of the stomach

Answer 30

1. The stomach functions to mix food with various substances and to move it to the small intestines for further processing. The digestion of proteins and fats begins in the stomach. As the stomach expands, the stomach muscles are stimulated to contract, causing stronger peristalsis
2. The stomach curves from the esophagus to the duodenum, where it joins the small intestines, at the pyloric sphincter. The cardia is the initial portion, followed by the fundus, the body and the antrum. The antrum extends to the pylorus. The right curvature is called the lesser curvature; the left side is longer and is called the greater curvature

Question 31

Describe the layers of the stomach wall, its blood supply and its innervation

Answer 31

1. The muscularis propria is made of three muscle layers. These include the outer longitudinal muscle fibers, the middle circular smooth muscle and the inner transverse fiber layer. These muscles cause the peristalsis, which results in the mixing the food
2. The next layer is the submucosa, which is mostly connective tissue with some blood vessels, some lymphatics and some nerves
3. The inner surface, or gastric mucosa, is covered with rugae, resembling wrinkles. This allows for the stomach to expand when contents enter from the esophagus
4. The blood supply of the stomach is drained through the portal vein. Arterial blood supply comes from the celiac axis
5. The vagus nerve provides parasympathetic innervation to the stomach, which stimulates secretion and motility. The sympathetic is responsible for pain, inhibition of secretion and of motility

Question 32

Discuss the gastric glands involved with digestion

Answer 32

The stomach functions to begin the process of digestion. This requires the secretion of substances to help ready the food for the small intestines. There are three glands involved in this: the cardiac glands, the oxyntic glands, and the pyloric glands

1. Cardiac glands are located immediately after the transition to the stomach. They secrete mucous and pepsinogen, which then becomes pepsin when it reacts with hydrochloric acid
2. The oxyntic glands, which are contained in the upper 2/3 of the stomach, are composed of four different cells: chief cells, parietal cells, mucous neck cells and endocrine cells. Aside from secreting hydrochloric acid, the parietal cells secrete intrinsic factor, which allows for the absorption of the important vitamin B12
3. Pyloric glands are located in the antrum and pylorus areas of the stomach. Along with cells that secrete mucus and pepsinogen, these glands have the G cells for secreting gastrin

Question 33

Discuss gastric cancer

Answer 33

1. Gastric cancer is almost always adenocarcinoma. 3% are of other origins, including carcinoid tumors, lymphoma, leiomyosarcoma or sarcomas. Gastric cancer can be in a localized area, but it can also be of a diffuse nature. Diffuse cancer spreads through areas of the superficial layer of the gastric lining
2. It’s occurrence can be associated with increasing age, male sex, family history and Helicobacter pylori. Patients present with pain, weight loss, vomiting, and occult blood
3. Cancers are commonly found in the antrum or the lesser curvature of the stomach. However, cancers related to gastric atrophy often affect the upper portion of the stomach

Question 34

Discuss the diagnosis and treatment of gastric cancer

Answer 34

1. X-rays can diagnose a lesion, but endoscopy is needed to obtain tissue for definitive diagnosis. Since gastric cancers can metastasize, an appropriate work up needs to be done to look for hematogenous, lymphatic or direct spread. The liver is the most common site for metastatic spread of gastric cancer
2. Surgery can be curative in some cases, requiring a partial gastrectomy. In this country, however, cancers are not usually diagnosed until the cancer is advanced. In those cases, surgery is for palliation. Surgery can relieve obstructive symptoms, manage bleeding or provide a method for adequate nutrition. Chemotherapy, radiation or a combination can be provided, but the prognosis is poor

Question 35

Discuss gastric varices

Answer 35

1. Gastric varices commonly occur in the upper part of the stomach. They result from the increased pressure due to portal hypertension. Diseases of the liver and portal circulation cause portal hypertension
2. Gastric varices are even more likely to cause death from gastrointestinal bleeding than are esophageal varices
3. Diagnosis is best accomplished with endoscopy
4. Acute treatment requires stabilizing the patient and treating the varices with tamponade via the Sengstaken-Blakemore tube or using octreotide
5. Long term treatment requires reducing the portal hypertension. This usually involves surgery to create a shunt for the portal circulation. The newer procedure of Transjugular intrahepatic portosystemic shunt or TIPS is a less invasive way to reduce portal hypertension

Question 36

Define hiatal hernia

Answer 36

1. Hiatal hernia occurs when part of the stomach pushes through the diaphragm into the chest. Some of these hernias slide back and forth through the diaphragm. It is more likely to occur in the older patient and in women. This abnormality can result in decreased LES pressure and reflux
2. There is also a rolling hiatal hernia in which the greater curvature juts into the chest cavity, while the LES stays below the diaphragm. This is less common. Although these individuals complain of fullness, they do not suffer from reflux
3. Diagnosis can be made by routine Chest x-ray, barium x-rays or endoscopy
4. Treatment requires weight loss, elevation of the head while sleeping, avoiding food for several hours before going to bed and medications such as H2 blockers and antacids

Question 37

Describe gastric outlet obstruction

Answer 37

1. Gastric outlet obstruction results when the passage of food is blocked from leaving the stomach. Patients present with vomiting, nausea, pain and symptoms of reflux. Some causes include masses, bezoars, polyps and caustic exposures
2. Test need to be conducted to determine outlet patency, such as radionuclide imaging, x-rays may also be useful
3. Infants are at risk of hypertrophic pyloric stenosis. The pyloric sphincter is dysfunctional, preventing food from leaving the stomach. These children have projectile vomiting and may suffer from dehydration and metabolic abnormalities
4. Diagnosis is accomplished by barium x-rays. Treatment requires surgery, referred to as pyloromyotomy

Question 38

Describe bezoars

Answer 38

1. Bezoars are balls of hardened material that collect in the stomach. Some of these are composed of food matter known as phytobezoars. These are usually made up of plant or vegetable materials. These can be associated with such diseases as achlorhydria, decreased gastric motility, poorly chewed food and gastroparesis
2. Other bezoars can be composed of hair, and these are referred to as trichobezoars. This usually occurs in young women who chew their hair. It may be related to a psychiatric disorder
3. Symptoms include fullness, anorexia, vomiting, perforation or obstruction. Sometimes they result in irritation and ulceration of the mucosal surface
4. Clinicians can attempt to disrupt phytobezoars endoscopically. Surgery may be needed if this is unsuccessful. Trichobezoars require surgical removal

Question 39

Discuss caustic injury of the stomach

Answer 39

1. Caustic injury to the stomach results from the ingestion of materials that damage the lining of the stomach. Both acid and alkaline substances can cause injury. It is more common for these substances to injure the more proximal gastrointestinal structures, but some individuals do suffer gastric injury
2. The exposure leads to ulceration, scarring and the risk of perforation
3. Patients need endoscopic examination to determine the extent of injury. Patients need to be evaluated for aspiration pneumonia or perforation
4. A common complication is stricture formation, which may require dilatation. Surgery may be required for severe scarring

Question 40

Discuss the Zollinger-Ellison (ZE) syndrome

Answer 40

1. ZE syndrome is a rare disease that causes tumors in the pancreas and duodenum. These tumors secrete gastrin, which causes the stomach to produce excess acid. This may lead to gastric and duodenal ulcers
2. The symptoms of this disease are those of peptic ulcer disease. Patients suffer from abdominal pain, nausea, vomiting, weight loss and bleeding
3. The diagnosis is made by measuring the level of gastrin in the blood. An endoscopy may be needed to check for gastric or duodenal ulcers
4. Treatment is directed towards reducing acid secretion in the stomach. The first line of therapy involves using proton-pump inhibitors such as omeprazole. Another option is use of the H-2 blockers like Cimetidine, but these are less effective. In general, however, these ulcers are less responsive to treatment than other ulcers
5. Surgery may be considered to remove the tumors and/or to treat the ulcers

Question 41

Discuss the nature of gastritis

Answer 41

1. Gastritis is the result of an inflammation of the lining of the stomach. This condition can be acute or chronic. The inflammation is the result of an irritant, such as excess acid production, certain medications or bile exposure from the duodenum
2. The acute form of this disease can be related to acute illness, trauma, surgery or alcohol
3. Chronic gastritis may be associated with aging. Helicobacter pylori, cancer, pernicious anemia or ulcers. The inflammation can be superficial, involving the upper part of the lining. Atrophic gastritis, on the other hand, involves the full lining. Thus there is atrophy of the gastric glands. With gastric atrophy, the lining is thinned with scant inflammation. There is loss of gastric glands
4. Diagnosis is best obtained by endoscopy. With chronic gastritis, there may be some bleeding that resolves spontaneously. Some patients develop a chronic anemia, however, with slow continual blood loss
5. Treatment is directed towards symptoms and complications, and may include H2 blockers, antacids, and sucralfate

Question 42

Discuss peptic ulcer disease

Answer 42

1. Peptic ulcer disease is the most common cause of upper gastrointestinal bleeding. Peptic ulcers commonly present with abdominal pain, particularly pain that manifests while sleeping. Some people with ulcers are not aware of them until bleeding occurs.
2. The mucosal lining of the gastrointestinal tract is disrupted, exposing the underlying tissue to damage from harmful substances. As the damage continues, blood vessels can be disturbed, leading to bleeding. In extreme cases, perforation can result
3. Peptic ulcers result from a number of causes:
   - Helicobacter pylori infection
   - Excessive exposure to certain drugs line non-steroidal anti-inflammatories
   - A history of ulcers in the family smoking
4. The association of stress and ulcer formation is controversial

Question 43

Discuss the diagnosis and complications from peptic ulcer disease

Answer 43

1. Although x-rays can reveal an ulcer, endoscopy is probably the preferred method for diagnosis. Endoscopic visualization detects smaller ulcers than x-rays. In addition, endoscopy allows for collection of tissue. This is particularly important for gastric ulcers, since they may be malignant
2. Ulcers commonly cause gastrointestinal hemorrhage. At times this can be massive. Ulcers also lead to perforation, which may be further complicated by peritonitis. Some ulcers lead to penetration, meaning the ulcer penetrates into another abdominal organ, such as the liver or the colon. Depending on the location, ulcers can interfere with gastric emptying, causing motility problems

Question 44

Discuss therapy for peptic ulcer disease

Answer 44

Treatment is tailored to the particular ulcer and associated complications. Although diet manipulation may be helpful in some individuals, medications are usually needed

1. Proton pump inhibitors interfere with the production of acid by inhibiting a necessary enzyme
2. H2 blockers interfere with histamine receptor sites on parietal cells. The action of these drugs reduces acid secretion
3. Sucralfate forms a barrier of protection in the damaged area, giving it insulation and time to heal
4. Antacids counter the acid produced in the stomach
5. Cytotec, a prostaglandin, offers protection because it opposes secretion of acid

Treatment for a bleeding peptic ulcer requires the control of the bleeding, volume replacement to prevent or reverse shock, and treatment for the underlying cause of the disease.

Complications from ulcer disease may need more invasive treatment, such as surgery

Question 45

Discuss gastroparesis

Answer 45

1. Gastroparesis refers to a delayed emptying of the stomach. Its cause is thought to be related to diabetic autonomic neuropathy. Gastric muscle activity is hypoactive or absent. Patients present with nausea, vomiting, abdominal distention, fullness, heartburn, abdominal pain or constipation
2. Diagnosis is accomplished by radiologic scintigraphy. The patient ingests a radiolabeled substance that is accompanied by foods and fluids. The path and rate of movement are followed. Endoscopy or upper gastrointestinal x-rays can also diagnose the disease
3. Treatment is directed at minimizing symptoms and complications. Treatment requires using medications that stimulate contraction of gastric muscles, such as Reglan, Propulsid, or Bethanechol. Medications to treat symptoms, such as antacids, may be used. Most importantly, careful control of blood sugar is imperative
4. Complications may include obstruction from bezoars, malnutrition and fluctuations in blood sugar

Question 46

Discuss the dumping syndrome

Answer 46

1. Dumping syndrome results from food entering the small intestines at a rapid rate. This may be due to a surgical complication from stomach surgery or vagotomy
2. Early symptoms include sweating and tachycardia. There may also be abdominal pain and bloating. These symptoms occur between 15-30 minutes after the beginning of a meal. Later symptoms resemble hypoglycemia, with sweating, faintness, shakiness and hunger. These symptoms occur between 90 and 120 minutes after the beginning of a meal
3. Diagnosis can be accomplished with endoscopy or barium x-ray studies
4. Treatment may include use of acarbose, which interferes with carbohydrate absorption, for late dumping symptoms. Early dumping may be treated with octreotide, a somatostatin analogue. This reduces certain secretions of hormones

Question 47

Describe the gross anatomy of the small intestines

Answer 47

The small intestines connect the stomach to the large intestines. It is approximately 600 centimeters long and is coiled within the abdominal cavity. It begins at the pyloric sphincter, the outlet of the stomach, and extends to the ileocecal valve, the start of the large intestines

The small intestines can be divided into three parts:
1. The duodenum is 25 centimeters long and is connected to the stomach at the pyloric sphincter. This is the shortest and widest part of the small intestine and is shaped like a C. It ends at the ligament of Treitz

2. The jejunum is 200 centimeters long and connects the duodenum to the ileum
3. The ileum is 300 centimeters long. It extends to the ileocecal valve where the large intestines start. The ileocecal valve controls the flow of contents into the large intestines

Question 48

Describe the blood and nerve supply to the small intestine

Answer 48

1. The small intestine is supplied with blood from two different contributors
   - the duodenum’s needs are met by the hepatic artery
   - the balance of the small intestine is supplied from the superior mesenteric artery
2. Drainage of blood from these organs is accomplished through the superior mesenteric vein
3. The small intestines are supplied with parasympathetic and sympathetic nerves via the enteric plexus. This is composed of the Meissner’s plexus in the submucosa, the Auerbach’s plexus in the muscular layers and the subserosal contribution
4. Parasympathetic stimulation increases contraction, secretory function and tone. Sympathetic innervation causes decreased motion and activity
5. Each villus is supplied by its own blood, lymph and nerve supply

Question 49

Describe the cross sectional layers of the small intestines

Answer 49

The small intestine has four layers

1. The outermost layer is composed of serosa and connective tissue
2. The next layer is the muscularis layer, composed of an inner layer of circular fibers and out layer of longitudinal fibers. Between these two muscle bands is the myenteric plexus, a collection of nerves
3. This is followed by the submucosa layer, made up of connective tissue, blood vessels, lymphatics and nerves
4. The innermost layer is the mucosa layer. The interior part of this is composed of columnar epithelium cells, followed by a band of connective tissue or the lamina propria, and then a layer of smooth muscle

Question 50

Describe the mucosal surface of the small intestines

Answer 50

1. The mucosal surface is structured to provide increased surface are for absorption of nutrients. The plicae circulares, formed by the mucosal and submucosal layers, form folds along the length of the small intestines. The surface is fringed with villi that jut into the lumen. Multiple microvilli extend form the surface of each villi. All these projections allow for more area for absorption
2. The crypts of Lieberkuhn, small glands, fall between the villi. These glands generate a new supply of columnar epithelium to replace the mucosal surface regularly. At the base of each of these are Paneth cells, which are thought to aide in controlling the microbiological population in the intestine. Brunner’s glands, which contain mucous and secretory cells, occur in the duodenum, and these secretions flow into the crypts

Question 51

Describe the immune contributions of the small intestine

Answer 51

1. The small intestine has abundant lymphoid tissue, making up 25% of the mucosal surface. The lymphoid tissue is composed of three different entities:
   - Peyer’s patches
   - Lymphocytes
   - Plasma cells
2. Peter’s patches, which occur in the ileum, are collection of lymphoid tissue. These areas help in antibody production for the body. They participate in the body’s immune system
3. The lamina propria contains both lymphocytes and plasma cells, which produce mainly immunoglobulin A. This antibody protects the mucosal surface.
4. The intraepithelial lymphocytes lurk within the epithelial cells and are largely T cells, which are involved in the immunologic function of the body

Question 52

Describe the function of the small intestines

Answer 52

1. The small intestines function to absorb nutrients and to secrete substances to help in processing food. These substances include mucus, digestive aids and various hormones. The small intestine also moves its contents toward the large intestine for continued processing
2. The secretory function is carried out by a number of different cells. The secretion of substances from the microvilli causes digestion of proteins and carbohydrates. Mucus is secreted by goblet cells around the villi. Other cells contribute mucus, hormones and other substances. The small intestines also receive contributions from the liver and pancreas to aid in digestion. In addition, the Brunner’s glands of the duodenum protect against the acidity of the stomach chyme

Question 53

Describe the absorption process of the small intestines

Answer 53

1. The small intestines are responsible for absorbing the nutritional substances that are essential to the body. The act of absorption occurs through some basic mechanisms, including hydrolysis, non-ionic movement, passive diffusion, facilitated diffusion and active transport. In addition, different substances enter via the small intestine at different sites. Conversely, the same substance can be absorbed by different mechanisms as it passes through the small intestines
2. In general, the duodenum absorbs Calcium and Iron; the jejunum absorbs fats, proteins and carbohydrate, and the ileum takes in vitamin B12 and bile acids
3. B12 is absorbed in the distal ileum by an active process employing intrinsic factor. Water soluble vitamins are usually absorbed by diffusion, however
4. Potassium is absorbed with sodium in the jejunum, but in the ileum, it is actively absorbed
5. Calcium is absorbed through several different mechanisms

Question 54

Discuss Meckel’s diverticulum

Answer 54

1. In 2% of the population, the ileum has a small congenital anomaly called a Meckel’s diverticulum. It is an outpouching off of the ileum with a mucosal surface similar to the small intestine. However, this vestigial pouch can also contain gastric and/or pancreatic cells, as well. Release of substances from these aberrant cells can lead to damage and bleeding in adjacent tissue. Meckel’s diverticulum is at risk for obstruction from volvulus or intussusception. This can cause pain, vomiting or bleeding
2. Diagnosis requires a radioisotope scan that detects abnormal secretion in the Meckel’s diverticulum. Surgery is required to either remove the Meckel’s diverticulum or, in some cases, the surround small intestinal tissue

Question 55

Discuss infections in the small intestine

Answer 55

1. The small intestines can be infected by organisms that behave in different ways in the bowel. These include:
   
   • Enterotoxigenic bacteria that stimulate secretions in the small bowel causing watery diarrhea, i.e. Escherichia coli, Vibrio cholerae
   • Bacteria that invade the mucosal surface, causing bloody stools and fever, i.e. Clostridium difficile, Vibrio cholerae and parahaemolyticus
   • Bacteria that invade beneath the mucosal surface, causing systemic illness, i.e. Yersinia enterocolitica and salmonella typhi
   • Viruses that cause diarrhea, i.e Norwalk virus and rotavirus
2. Diagnosis requires evaluating exposures and travel and evaluation of stools by cultures and stains. Treatment requires fluid replacement and appropriate antibiotics for identified organisms

Question 56

Discuss Giardiasis

Answer 56

1. Giardiasis affects the proximal small bowel by the parasite Giardia lamblia. The organism gains entry via contaminated water or food. Once ingested, the cysts release trophozoites, which cling to the intestinal lining
2. Although most are asymptomatic, some exhibit diarrhea. Children may also complain of pain, and headaches, along with nausea and vomiting
3. Diagnosis can be accomplished by evaluating the stool for parasites and Giardia antigen. Endoscopy can also be done to collect specimens of contents and mucosa
4. Flagyl is the drug of choice. Repeat cultures may be done after treatment. Sometimes a second course is required. If infection persists, patients can be given Atabrine and Flagyl for two weeks

Question 57

Discuss Cryptosporidiosis and Diphyllobothriasis

Answer 57

1. In the past, Cryptosporidiosis was extremely rare. With the appearance of the AIDS epidemic, with its concomitant immunosuppression, cases have increased in number. The disease is the result of infection by the Cryptosporidium parasite by fecal-oral route from animals to humans. It can also be water-borne

• The disease may last for only a few days to weeks. For the immunocompromised host, however, infection can be fatal
• The disease is diagnosed by checking the stool for the parasite or by evaluating small bowel tissue
• Treatment measures depend on the severity of symptoms. At a minimum, fluid and electrolyte status must be normalized. For those with severe cases, treatment can include Flagyl or other drugs

2. Diphyllobothriasis, a fish tapeworm, strikes those who consume raw fish. The tapeworm, which attaches to the intestinal lining, may cause B12 deficiency. Therefore, patients may have no symptoms until the B12 deficiency causes nerve symptoms. Diagnosis is accomplished by stool examination. Treatment is with Niclosamide

Question 58

Discuss infestations by Strongyloidiasis and Ascariasis

Answer 58

1. Strongyloidiasis is caused by the intestinal parasite, Strongyloides stercoralis. Patients develop fever, skin rash and cough, followed by gastrointestinal symptoms. Since the lifecycle of this parasite can occur in one person, there is the possibility that the individual can become hyper-infected. The hyper-infected patient has more severe and widespread disease and is at risk for lethal complications
2. Diagnosis can be accomplished with small intestinal biopsy, x-rays, stool tests and blood tests. Treatment requires the use of thiabendazole
3. Ascariasis results from infection by the parasite Ascaris lumbricoides, which is commonly found in the southeastern United States. Once the parasite egg is ingested, it remains in the gut for about 6 months. At that time, it passes through the intestinal wall and enters the circulation, causing fever, coughing and Hemoptysis. Patients may complain of pain or change in bowel habits. A common complication is obstruction
4. Diagnosis is accomplished by stool examination. Treatment requires use of mebendazole. Surgery may be needed to relieve obstruction

Question 59

Discuss Crohn’s disease

Answer 59

1. Crohn’s disease is one of the diseases classified as inflammatory bowel disease. Although it is more likely to affect the distal ileum, it can involve any part of the gastrointestinal tract. The disease causes inflammation in the submucosal area in a patchy pattern
2. The actual cause is not known, but some suspected participants are immunologic mechanisms, infections agents or genetics
3. The disease alternates between inflammatory attacks and relative quiet. When active, the disease causes abdominal pain, nausea and bloody diarrhea. These symptoms can be severe, and patients can suffer from malnutrition. Children may present with failure to thrive
4. In some patients, the disease causes extra-intestinal symptoms, such as arthritis, skin lesions and eye inflammation
5. Diagnosis is accomplished with X-rays or endoscopy. Endoscopy offers the advantage of obtaining tissue for diagnosis
6. Treatment is directed at the inflammatory process with drugs such as sulfasalazine, steroids or agents that alter immune responses
7. Complications include obstruction, bleeding, stricture formation, and malabsorption. These complications must be treated accordingly

Question 60

Discuss vitamin B12 deficiency

Answer 60

1. Vitamin B12 is absorbed in the terminal ileum by the aid of intrinsic factor, which is released by the parietal cell of the stomach lining. It is an essential vitamin, but symptoms of a deficiency take a long time to manifest themselves
2. A number of different abnormalities lead to this disorder. Some of those include pernicious anemia, loss of gastric mucosal surface or diseases that disrupt the distal ileum
3. Diagnosis can be made using the Schilling test, a test that measures the path of radio-isotope labeled B12 with and without added intrinsic factor
4. Treatment may require use of B12, but it also includes correcting any underlying abnormalities that interfere with B12 absorption

Question 61

Discuss celiac disease

Answer 61

1. Celiac disease is a genetic disorder that affects 1 in 300 Americans. These individuals are unable to tolerate gluten, which is found in wheat, barley, rye and possibly oats. Ingesting products containing gluten causes an immunologic reaction in the intestines. The surface of the intestine is damaged, and the villi are flattened. This results in a decreased ability to absorb nutrients. This leads to malabsorption and malnutrition
2. Although the specific cause is not known, risk factors for the disease include a family history of the disease, being a woman and being of northwestern Europe descent
3. Symptoms of gluten exposure include abdominal cramping, bloating, gas and diarrhea. If malabsorption develops, other systemic problems may develop, such as osteoporosis from lack of calcium absorption

Question 62

Discuss diagnosis and treatment of celiac disease

Answer 62

1. Celiac disease is diagnosed by a blood antibody test. Additionally, an upper endoscopy with a small bowel biopsy obtains tissue for diagnosis. Sampling of the small bowel should occur in the distal ileum and the jejunum. The tissue has a characteristic flattened appearance, due to the atrophy of the villi
2. There are many false negatives with biopsy, however, because the entire intestinal wall is not affected simultaneously. Thus, disease can be missed. A positive biopsy, on the other hand demonstrates that the patient has celiac disease
3. Some celiac patients suffer from Dermatitis herpetiformis. Although the specific cause is not known, those individuals develop blistering skin lesions over the elbows and/or knees
4. Treatment is strict avoidance of any gluten-containing products, which is often not an easy task

Question 63

Discuss Whipple’s disease and tropical sprue

Answer 63

1. Whipple’s disease is quite rare and presents with abdominal pain, diarrhea, arthralgias and malabsorption. While the exact pathogenesis is obscure, the disease is caused by exposure to T. Whipplei, a bacteria found in sewage and soil. This bacteria is not a common agent in the environment and exposure does not always progress to Whipple’s disease. It most commonly infects white males with heavy occupational exposure to soil

• Diagnosis is accomplished by obtaining tissue from the small bowel. Examination of the tissue reveals macrophages and cytoplasmic granules
• Treatment requires a 2-week course of intravenous antibiotics. After completion of this course, the patient is given 10-12 months of Tetracycline

2. Tropical sprue strikes those in the tropics, causing diarrhea and malabsorption. The intestinal wall undergoes progressive changes, with flattened villi and inflammatory cell collections. Treatment may require using folic acid and tetracycline

Question 64

Discuss short bowel syndrome

Answer 64

1. Short bowel syndrome is caused by a decrease in the available length of the small intestine. This can be the result of resection, congenital abnormalities, or Crohn’s disease. Since the small intestine is needed for absorption of nutrients, those with short bowel syndrome suffer from malabsorption and malnutrition. The deficiencies in nutrients depend on the area of bowel involved
2. An important consideration is the ileocecal valve. This is the gatekeeper for food entering the large intestine. It also is a barrier to the encroachment of large intestinal micro flora spreading into the small intestine, which might further exacerbate the problems
3. These patients need nutritional support. This is usually accomplished with enteral nutrition. The bowel makes certain compensations for the shortened bowel, but the patient needs nourishment to support them, at least in the short term

Question 65

Discuss tumors of the small bowel

Answer 65

Tumors of the small bowel include:
1. Primary small intestinal tumors are not particularly common, accounting for less than 5% of all gastroenteric tumors. These tumors include lymphomas, alpha heavy chain disease, carcinoma, carcinoid tumors or hamartomas

2. The Peutz-Jeghers syndrome causes hamartomas in the gastrointestinal tract, usually in the small bowel
3. Hamartomas are benign tumors that are composed of normal tissue that is collected in a disorganized mass. Other distinguishing features of this syndrome are pigmentation of the skin
4. Primary tumors of the small bowel can occur and are predominantly adenocarcinomas
5. Secondary tumors are most likely caused by breast cancer, lung cancer or melanoma
6. Alpha heavy chain disease results from the abnormal production of the heavy chain of immunoglobulin A. This leads to malabsorption. This usually progresses to malignant lymphoma
7. Carcinoid tumors are more likely to be found in the ileum and appendix

Question 66

Discuss the Carcinoid syndrome

Answer 66

1. Carcinoid tumors are often asymptomatic, coming to notice by accident. These tumors can cause problems to patients by causing obstruction. Approximately 1/3 of these tumors are found in the small bowel, and they are often multiple. Some of these can metastasize particularly to the liver
2. The syndrome results from the tumor secreting excess hormones that result in various symptoms, such as flushing, wheezing, and diarrhea. A high percentage of patients develop right heart fibrosis, particularly of the tricuspid valve
3. Diagnosis can be done by endoscopic biopsy of tissue or by direct biopsy of the tumor via the abdominal wall
4. Surgical removal should be attempted if possible. Chemotherapy and radiation have had limited success. Medical treatment should be direct at symptoms

Question 67

Discuss the gross anatomy of the large intestine

Answer 67

1. The large intestine extends from the ileocecal valve to the anus in an upside-down U shape outlining the abdomen. It is 4 to 5 feet long and it is composed of 5 sections: the ascending colon, the transverse colon, the descending colon, the sigmoid colon, and the rectum
2. The large intestine starts at the ileocecal valve, which controls influx from and reflux to the small intestine. This area of the large intestine is called the cecum, which has the appendix affixed to it
3. Digestive contents move from the cecum to the ascending colon, which runs along the periphery of the right side of the abdomen. At the liver, it bends to run across the top of the abdomen as the transverse colon. At the spleen, located in the upper left quadrant of the abdomen, the colon again bends to head down the left side of the abdomen. At the lower left quadrant of the abdomen, the colon forms an S-shaped contortion, referred to as the sigmoid colon. This then joins the rectum above the pelvic area

Question 68

Describe the outer three layers in a cross-section of the wall of the large intestine

Answer 68

The large intestinal wall is composed of four layers:

1. The serosa covers all of the large intestine but the rectum
2. The muscularis is made up of the tenia coli, an inner band of circular muscle and an outer band of longitudinal muscle. Auerbach’s plexus, a collection of nerves, is nestled between these layers. Since these are not as long as the intestine itself, the tenia coli compresses the intestinal wall into folds. These small puckers are called haustra
3. Next to this is the submucosal layer, composed of connective tissue, blood vessels, lymphatics and nerves, part of which is the Meissner’s nerve plexus
4. The muscularis mucosae, compose of smooth muscles, separate this layer from the mucosal layer

Question 69

Describe the mucosal surface of the large intestine

Answer 69

1. The mucosal surface is flat and is lined by columnar epithelial cells and goblet cells. The large intestine does not have villi. The inner lining of the large bowel is gathered in folds, referred to as the plicae semilunares
2. Unlike the rest of the large intestine, the rectum does not have a serosa layer. The mucosal layer is composed of rectal columns, or longitudinal rows, which each have an artery and vein. This mucosal layer meets the anal area at the mucocutaneous border. This border is also where the blood supply changes

Question 70

Discuss the blood supply and innervation of the large intestine

Answer 70

1. The large intestine is supplied by different arteries
   - on the right side, the large intestine is supplied by blood from the superior mesenteric artery
   - on the left side, the large intestine is supplied by the inferior mesenteric artery. Venous blood returns to the circulation via the inferior and superior mesenteric veins
2. The balance of the large intestine, the rectum and anal canal, are supplied by a branch of the inferior mesenteric artery, the hemorrhoidal artery. The rectum also is supplied by the hypogastric artery. Venous drainage varies in this area. In the rectum, the blood flows into the superior hemorrhoidal veins, which join the portal veins. The anal area returns its venous blood through the inferior hemorrhoidal veins
3. Parasympathetic innervation of the large intestine leads to increased activity and secretion; it also inhibits the rectal sphincter. Sympathetic nerves reduce activity and secretions, while stimulating the rectal sphincter

Question 71

Discuss the function of the large intestine

Answer 71

1. The motility of the colon operates to mix contents and to help absorb contents. The waste products are eliminated by action of the internal and external sphincter. Movement is slower in the large intestine than in the small intestine
2. The large intestine more readily absorbs water than does the small intestine. The bulk of this takes place in the ascending colon
3. The large intestine is populated by normal flora, or organisms. These organisms allow for help in breaking down waste material, breaking down bile acids, production of vitamin K, control of overpopulation by certain undesirable bacteria, and inactivating pancreatic enzymes. These same organisms can be deleterious, as well, by participating in colitis, diarrhea and infections
4. Passage of material from the rectum is controlled by two sphincters: the internal sphincter and the external sphincter. The internal sphincter and the external sphincter. The internal sphincter, made of smooth muscle, and an external sphincter, made of striated muscle. Voluntary control of the bowels is the function of the levator ani muscles, which surround the rectum

Question 72

Describe some disease that present with multiple polyps

Answer 72

There are several diseases characterized by multiple polyps, including juvenile polyps, familial polyposis coli, Gardner’s syndrome and Peutz-Jeghers syndrome

1. Juvenile polyps occur in young people, usually before the age of 5. This entity is rare after adolescence
2. Familial polyposis coli is a disorder that runs in families resulting in multiple polyps. Once the diagnosis is established, surgery to remove the polyps needs to be done. These polyps can become cancerous
3. Gardner’s syndrome is also a familial disease. Patients develop polyps and osteomas. Since the polyps can become cancerous, surgery is necessary to remove the polyps
4. Peutz-Jeghers syndrome causes hamartomas in the large intestines. These individuals also have pigmented lesions on the skin. Although these lesions can become cancerous, many cause no problems

Question 73

Define angiodysplasia

Answer 73

1. Angiodysplasia can be found anywhere in the gastrointestinal tract, but these lesions occur most commonly in the cecum and ascending colon. Angiodysplasia refers to a collection of dilated blood vessels, associated with the elderly. Although angiodysplasia is often asymptomatic, it can present with gastrointestinal bleeding. Differentiating this disease from other possible causes of bleeding can be difficult
2. Diagnosis is accomplished by colonoscopy or angiography. Resection of the affected area clears the problem. Other treatments may include electrocautery or laser. These latter techniques have higher complication rates in this patient population, however

Question 74

Discuss irritable bowel syndrome (IBS) in adults and children

Answer 74

1. Irritable bowel syndrome, or IBS, is marked by motility problems of the intestine without demonstrable organic disease. Patients suffer alterations of diarrhea and constipation and pain usually in the form of ulcerative colitis and/or Crohn’s disease
2. Treatment includes a high-fiber diet drugs for abdominal pain and psychosocial support
3. Children present with a recurrent complaint of pain, called chronic recurrent abdominal pain syndrome. They have intermittent bouts without any organic abnormality. Some children also have dizziness, headache and nausea. Drugs are discouraged, but psychological support is emphasized

Question 75

Discuss ischemic colitis

Answer 75

1. Ischemic colitis is caused by a lack of blood supply to an area of the small or large intestine. This abnormality is more likely to occur at the splenic flexure or in the sigmoid colon. The blood supply can also be compromised by systemic illnesses that cause hypotension, which leads to a failure to perfuse the bowel
2. The onset of ischemic colitis is characterized by abrupt pain, fever, abdominal distention, and bloody diarrhea. X-ray findings reveal abnormalities in the mucosa of the affected area in what is called a “thumbprint” pattern
3. The course of the disease is usually self-limited. Some individuals fail to resolve, going on to develop infarction and peritonitis. These complications require surgical intervention

Question 76

Discuss some causes of colitis in infants

Answer 76

1. Necrotizing enterocolitis affects neonatal patients. The cause is unclear, but suspected participants include exposure to formula, invasive bacterial infection or some form of ischemic injury. The disease affects the colon or the distal small intestine, causing bloody stools, distention of the abdomen and vomiting. X-ray of the bowel reveals air in the intestinal wall or portal system, called pneumatosis intestinalis. Supportive therapy may ease the symptoms, but some infants need surgery
2. Cow’s milk protein-induced enterocolitis affects children from birth until 6 months. These children are sensitive to milk exposure and can present with different symptoms including vomiting, diarrhea, failure to thrive, bloody stool and irritability. Diagnosis is made by challenging the infant with milk or obtaining tissue to look for inflammation. Affected children should be switched to hypoallergenic formulas

Question 77

Discuss ulcerative colitis

Answer 77

1. Inflammatory bowel disease of the large intestine can be either ulcerative colitis or Crohn’s disease. Ulcerative colitis, which does not affect the small intestine, causes ulcerations in the mucosal surface. Scarring can result in shortening and narrowing of the large intestine. The disease often begins in the distal colon and spreads throughout the rest of the large intestine. The inflammatory process is usually uninterrupted
2. Patients present with bloody diarrhea, anorexia, fever, abdominal tenderness. There can be symptoms outside of the bowel, such as arthritis, liver problems or sclerosing cholangitis. Patients can have periods of quiescent disease interspersed with flares of activity

Question 78

Discuss the diagnosis, treatment and complications of ulcerative colitis

Answer 78

1. The diagnosis of ulcerative colitis can be made by appropriate x-ray studies and endoscopic evaluation
2. Treatment requires adequate nutrition with avoidance of foods that cause symptoms. Drugs can also minimize symptoms. These include corticosteroids, 5-aminosalicylate drugs and immunosuppressives. For unresponsive patients, surgery may be needed
3. Complications include toxic megacolon, a distention of the colon, which requires immediate intervention. This complication can lead to perforation, infection or bleeding
4. At first, the patient may respond to antibiotics, bowel rest and fluid support. Surgery may be necessary to remove the colon
5. Patients with ulcerative colitis are at increased risk of colon cancer and need to be followed carefully

Question 79

Discuss pseudomembranous colitis

Answer 79

1. Pseudomembranous colitis involves inflammation of the mucosal layer with areas covered by a pseudo-membrane. This disease is usually associated with an exposure to a toxin such as an antibiotic. Patients develop diarrhea, cramps pain and fever. Most cases are the result of an overgrowth of the organism. Clostridium difficile. There have been cases of pseudomembranous colitis caused by other organisms, but this is rare
2. Diagnosis is accomplished by endoscopy and biopsy. Stools can also be evaluated for the presence of the toxin
3. Treatment requires a course of antibiotics and possibly administering medications that bind the organism
4. Although most people have resolution of symptoms, some need to be hospitalized

Question 80

Discuss Crohn’s disease of the large intestine

Answer 80

1. Crohn’s disease, another form of inflammatory bowel disease, can affect the small or large intestine. The inflammatory process involves the entire thickness of the gut wall and is not necessarily continuous. The symptoms are similar to ulcerative colitis, but pain is more pronounced
2. Like ulcerative colitis, Crohn’s disease may affect areas outside the bowel, such as joints, the skin and the liver
3. Treatment is aimed at quelling the inflammation. Fluid and electrolyte support help maintain the patient’s status. Drugs can offer some anti-inflammatory aid. Some drugs include the 5-aminosalicylate drugs, corticosteroids, and immunosuppressive drugs
4. Complications include bleeding, stricture formation, fistula formation and perforation

Question 81

Discuss radiation enteritis

Answer 81

1. Radiation enteritis results from injury to the abdomen from radiation therapy. If the bowel wall is affected, patients develop a change in bowel habits, diarrhea and tenesmus
2. Those affected during treatment develop an acute form of the disease. Patients present with nausea, cramps and changes in routine bowel movements
3. If chronic damage develops, patients develop bleeding, strictures, obstruction and perforation. These symptoms may develop anywhere from 3 months to 30 years after radiation treatment
4. The chronic form of this disease can be progressive and resistant to treatment. Use of intralumenal steroids or sulfasalazine may help. Surgery may be needed for those with serious abnormalities, such as obstruction or perforation

Question 82

Discuss some parasitic diseases of the colon

Answer 82

1. Amebiasis is caused by the parasite Entamoeba histolytica. Infection is most often by fecal-oral contamination. Symptoms may include diarrhea, appendicitis or abscesses in organs. Some individuals develop dysentery, with fever, nausea and vomiting
2. Stool evaluation reveals the parasite. Other possible ways to diagnosis amebiasis include sigmoidoscopy or barium enema. Abscesses are diagnosed via x-rays or biopsies
3. Treatment requires Yodoxin, often accompanied by Flagyl
4. Trypanosomiasis is a parasitic disease, called Chagas’ disease, caused by Trypanosoma cruzi. It is transmitted by a bug bite, along with several other methods. The organism causes an intense inflammation locally and may become blood borne. It tends to invade the heart, the esophagus and the colon, destroying nervous tissue. This leads to enlargement of the affected organ. Diagnosis is made by finding the parasite in the blood or tissue. Extended use of the drug Lampit is needed to treat the disease
5. Trichuriasis, or whipworm, is called by Trichuris trichiura. The parasite is spread by fecal-oral contamination, congregating in the cecum and ascending colon. Diagnosis is made by stool examination, and the infection responds well to mebendazole (Vermox)

Question 83

Define diverticulosis and diverticulitis

Answer 83

1. Diverticulitis is an infection of a diverticulum. Diverticula are bulging sacs formed in the colon. These protrusions, evidence of diverticulosis, are formed at weakened areas of the intestinal wall, and are prone to infection, called diverticulitis. These abnormalities can occur anywhere in the colon, but are more commonly found in the descending and sigmoid colon located in the left side of the abdominal cavity
2. The occurrence of diverticula increases with age, and rarely occurs in those younger than 40. Other potential contributing factors may include lack of dietary fiber, constipation and obesity
3. Although most patients with diverticulosis have no symptoms, a few present with complaints, such as constipation, cramps, diarrhea or bloating. The patient with diverticulitis displays abdominal pain, constipation and fever

Question 84

Discuss the treatment and complications of diverticular disease

Answer 84

1. Treatment includes appropriate antibiotics and a low-fiber, liquid diet. If diverticulitis dose not respond to treatment or recurs frequently, surgery may need to be performed. The affected area, usually located in the sigmoid colon, is drained and the section with the diverticulum is removed
2. Complications of diverticulitis include abscess formation, obstruction and peritonitis. An abscess, or collection of pus, can form. Infrequently, the infection can spread into the abdominal cavity, causing peritonitis. This is a grave complication
3. Intestinal obstruction can occur, as well. Because of the swelling or possible scarring from the infected diverticula, the ability to move intestinal contents can be blocked. The obstruction needs to be treated to avoid intestinal perforation

Question 85

Discuss colon cancer

Answer 85

1. Colon cancer is one of the most common forms of cancer in this country. If detected early, the prognosis is good. Because of that, the American Cancer Society recommends screening the population for colon cancer. Depending on age and risk, the recommendations may include sigmoidoscopy, colonoscopy or stool evaluation for blood. Those at increased risk include patients with a family history of colon cancer, people with high risk diseases, like ulcerative colitis or familial polyposis, or a prior history of certain cancers
2. The majority of tumors are adenocarcinomas, which are usually located in the cecum, ascending colon or sigmoid colon. Tumors of the right side of the bowel have the onset of symptoms later in the disease process, but can include blood in the stool, weight loss, anorexia and pain
3. Surgery may be used for treatment or for palliation. Patients may also receive radiation, chemotherapy or both

Question 86

Discuss intestinal obstruction

Answer 86

1. The large intestine can be obstructed by many different entities, such as cancers, strictures, or polyps. Impingement on the lumen can also occur from extra-intestinal causes, such as visceral tumors. The causes of the obstruction can be categorized into three main groups:
   - mechanical
   - neurogenic
   - vascular
2. Patients present with pain, nausea, vomiting and distention. An obstruction can present with different effects .if the blood supply is not affected, the obstruction is called simple. It the blood supply is impinged upon, the obstruction is called strangulated. If the blood supply is totally interrupted, it is called incarcerated
3. Diagnosis may be accomplished by careful evaluation and x-ray studies

Question 87

Give examples of mechanical, neurogenic or vascular obstruction of the large bowel

Answer 87

1. One form of mechanical obstruction of the large intestine is Hirschsprung’s disease, a congenital lack of neuronal tissue. The lack of this innervation inhibits the bowel’s ability to relax, causing the dilation of the bowel. Symptoms may include diarrhea, nausea, vomiting, constipation, or perforation. The most dreaded complication is ischemia from over distention. Diagnosis is made by barium enema and tissue biopsy. Treatment requires surgery to remove the effected colon segments
2. Intestinal pseudo-obstruction, a form of neurogenic obstruction, results from poor intestinal motility. Patients present with weight loss and intermittent abdominal distention. An x-ray picture of paralytic ileus is seen, with fluid levels in dilated bowel. There is a chronic form of this disorder that may be associated with other organic diseases
3. Vascular obstruction results when the blood supply to the intestine is interrupted by emboli disease or atherosclerotic disease. The resulting ischemia can lead to a life-threatening illness

Question 88

Discuss the function and gross anatomy of the biliary system

Answer 88

1. The gallbladder and its associated ducts comprise the biliary system. The gallbladder stores bile that is made by the liver. Bile, a greenish-yellowish fluid, functions to eliminate wastes from the liver and to help break down fat during digestions
2. When food is ingested, the gallbladder is stimulated to contract by the enzyme cholecystokinin-pancreozymin. This contraction forces the bile into the cystic duct, which joins with the hepatic duct to from the common bile duct. The common bile duct passes through the head of the pancreas and joins the pancreatic duct. Bile, along with pancreatic enzymes, flows into the duodenum through the ampulla of Vater. This opening into the duodenum is controlled by a muscular structure, the sphincter of Oddi. It regulates the flow of bile and pancreatic secretions into the small bowel and restricts reflux from the intestinal tract

Question 89

Discuss what bile is composed of and how it works

Answer 89

Bile is composed largely of water. Most of the water is re-absorbed however. It also consists of bile salts, fatty acids, lipids, bilirubin and other substances

1. Bile functions to provide a means of eliminating waste products from the liver
2. It is also a key factor in digesting and absorbing certain nutrients and activating certain digestive enzymes
3. It also function to counteract the acidic content in the duodenum and to facilitate the absorption of some minerals. When the flow of bile is obstructed, the concentration of bile in the blood increases. The excess bilirubin is deposited in various tissues, like the sclera of the eye, giving that tissue a yellowish hue or jaundice

Question 90

Define Cholelithiasis

Answer 90

1. Cholelithiasis or gallstones are formed when abnormal concentrations of cholesterol, bile or bilirubin harden into a stone. A slow-emptying gallbladder can increase the chance of forming stones
2. Gallstones are usually composed of cholesterol or a mixture including cholesterol. About 20% are pigmented stones, composed of bilirubin mixed with other substances. They can be tiny or the size of a golf ball. Patients may have one stone or many
3. The risk of forming Concretions depends on the makeup of the stones. Cholesterol stones are increased in females, with exposure to estrogen, with some hyperlipidemias, and with certain drugs. Pigmented stones are more likely to occur in those with hemolysis, alcoholism, total Parenteral nutrition, and biliary infections

Question 91

Describe the symptoms and treatment options for Cholelithiasis

Answer 91

1. Often gallstones are asymptomatic, but they can cause symptoms when they increase in size or if they cause obstruction. If a patient develops symptoms, these symptoms commonly follow a fatty meal or occur at night. Symptoms include pain, nausea, vomiting, indigestion, jaundice, fever, chills
2. Diagnosis is made by abdominal ultrasound. Also x-ray studies can be done. If these are negative, but the symptoms are suggestive of biliary disease, an ERCP may be done
3. Treatment for symptomatic stones usually involves surgery to remove the gallbladder or cholecystectomy. With symptomatic pigmented stones, surgery is the only option
4. The treatment for cholesterol stones, on the other hand, has some alternative choices. Certain medications can potentially dissolve these stones. In addition, biliary lithotripsy can be used. This involves using sound waves through the abdominal wall to dissolve the stones

Question 92

Discuss Cholecystitis

Answer 92

1. Cholecystitis is inflammation of the gallbladder. Although this can occur without gallstones, this is rare except in the pediatric population. It is most commonly due to an obstruction of the cystic duct by a gallstone, or acute calculous Cholecystitis. Risk factors may include obesity, diabetes, hemolytic anemia or pregnancy. Symptoms may include abdominal pain, fever, nausea, vomiting, and pain exacerbation when consuming fatty foods
2. Diagnosis may be accomplished with ultrasound or radioisotope imaging studies
3. Although removing the gallbladder is the best treatment, not every patient can undergo the procedure. With those patients, a cholecystostomy may be done, providing drainage via a temporary tube placement. This can be accomplished by ERCP, by surgery or by Percutaneous drainage
4. Complications may include perforation, peritonitis, or gallstone ileus

Question 93

Discuss primary sclerosing cholangitis

Answer 93

1. Primary sclerosing cholangitis is a disease that causes strictures in the bile ducts .the obstruction to the flow can lead to liver disease. The majority of patients have a history of ulcerative colitis; it can also be seen with Crohn’s disease. This disease affects men more commonly than women and can occur in relatively young patients
2. Individuals with this disease may develop jaundice, pruritis, pain and liver dysfunction. Diagnosis is accomplished by ERCP, ultrasonography or biopsy. Treatment for advanced disease requires liver transplant. Without a transplant, symptomatic patients go on to develop liver failure and portal hypertension. There is an increased risk for development of cholangiosarcoma in these patients

Question 94

Discuss cancers of the biliary system

Answer 94

1. Gallbladder cancer is most often adenocarcinomas. These cancers spread locally or lymphatic metastasis. Patients complain of pain, anorexia, and weight loss. These tumors often co-exist with gallstones
2. Diagnosis may be accomplished by imaging studies, such as Cholangiograms or by ERCP
3. Treatment is directed at symptomatic relief. Surgery may be performed for small tumors, but invasive therapy has little benefit. For symptoms of obstruction, a stent may be placed to relieve the obstruction and reduce the risk of infection. The prognosis is poor, with a five-year survival rate of 5%
4. The most common form of cancer in the biliary system is adenocarcinoma. Patients present with jaundice, intermittent abdominal pain, nausea and weight loss. At diagnosis, the cancer is usually found to have spread. Although surgery can be done to remove the tumor, the prognosis is poor
5. Children are at risk of developing botryoid embryonal rhabdomyosarcoma, a tumor with a poor prognosis

Question 95

Describe the anatomy of the pancreas

Answer 95

1. The pancreas stretches across the upper abdomen, starting behind the duodenum and stomach and ending behind the spleen. The pancreas functions as both an exocrine and endocrine organ. The exocrine cells, or acinar cells, are cuboidal cells that cluster around a network of ducts. These ducts connect to the duct of Wirsung, which travels through the entire organ, collecting secretions. This central duct meets the common bile duct and these two systems drain into the duodenum
2. The endocrine function of the pancreas is carried out by the endocrine cells located in the islets of Langerhans. These cells comprise about 1% of the pancreatic cells

Question 96

Describe the endocrine and exocrine function of the pancreas

Answer 96

The endocrine function of the pancreas is performed by three different endocrine cells that secrete their products directly into the blood

1. The alpha cells release glucagon when there is a drop in blood sugar concentration. This substance increases glucose in the blood by promoting glucose formation from glycogen stored in the liver
2. The beta cells are stimulated to release insulin when the blood sugar level is high, allowing cells to act on glucose through metabolism or storage
3. The exocrine function of the pancreas is due to the secretion of pancreatic enzymes by acinar cells. The main enzymes include amylases for carbohydrate absorption, lipases for fat digestion and proteases for protein digestion

Question 97

Discuss acute pancreatitis

Answer 97

1. Acute pancreatitis is the abrupt onset of an inflammation of the pancreas. There are many causes, including gallstone obstruction, alcohol, infections, drugs, hyperlipidemias and hyperparathyroidism. Symptoms include pain, nausea, vomiting, fever and possibly shock. Blood tests reveal an elevated amylase and lipase. Further details are obtained by imaging studies, ultrasound or endoscopic studies
2. Treatment is supportive, sometimes requiring intensive care. Depending on the cause, different therapies may be offered, such as antibiotics. If gallstones are the cause of the pancreatitis, the patient will need surgery or ERCP
3. Necrotizing pancreatitis is a destructive acute pancreatitis that can be very serious. Pancreatic tissue is necrosed and at risk for infection, pseudocyst formation and pancreatic failure. 1/3 of patients die from this form of pancreatitis
4. Interstitial pancreatitis is a milder form that affects interstitial tissue, causing less damage. Some of these cases, however, may require intensive care, as well

Question 98

Discuss chronic pancreatitis

Answer 98

1. Chronic pancreatitis is the result of continued inflammation, leading to destruction of pancreatic tissue. In this country, alcohol is the most common cause of chronic pancreatitis. Other etiologies to be considered are cystic fibrosis, malnutrition, and familial pancreatitis. Symptoms include pain, weight loss, diabetes, and malabsorption. Diagnosis depends on the history appropriate x-ray studies, and studies involving the cause of the symptoms
2. Treatment is directed at pain relief and control of symptoms. Depending on the cause of the disease, interventions might include ERCP with interventions or surgery. Surgery may be performed to remove parts of the pancreas or to drain areas

Question 99

Discuss pancreatic pseudocysts

Answer 99

1. Pancreatic pseudocysts are collections of pancreatic materials that are encapsulated without a true epithelial layer. These are associated with both acute and chronic pancreatitis and can be single or multiple. The majority of pseudocysts disappear without intervention. Symptoms may include pain, nausea, vomiting, and weight loss. Diagnosis is by imaging studies
2. If the pseudocyst and its associated symptoms that persist, the pseudocyst may need to be drained. This can be done via surgery, percutaneously or ERCP. Intervention must be provided immediately if the pseudocyst becomes infected, ruptures or hemorrhages
3. Complications include peritonitis, bleeding and obstruction

Question 100

Discuss pancreatic adenocarcinomas and cystic tumors

Answer 100

1. Pancreatic cancers are mostly adenocarcinomas. Patients complain of pain, vomiting, weakness, and weight loss. Often patients will develop jaundice. Diagnosis is accomplished by imaging studies and tissue biopsy, either percutaneously or via ERCP
2. The prognosis of this disease is poor. Most interventions are for palliation. Surgery, such as the Whipple operation, can be done. Stent placements help with obstructive complications of the biliary tree, duodenum or the pancreas
3. Pancreatic cystic tumors can occur anywhere in the pancreas, although most often in the head of the pancreas. These tumors contain fluid and are difficult to differentiate from pseudocysts

Question 101

Discuss some other endocrine tumors of the pancreas

Answer 101

1. Insulinomas are beta cell tumors causing hypoglycemia. Usually there is only one tumor
2. Glucagonomas are alpha cell tumors causing excess glucagon release. Patients manifest the skin disease, necrolytic migratory erythema, which presents as an erythematous rash that blisters and often develops a bronze pigment in healing. These patients often have concomitant diabetes
3. Somatostatinomas have excess somatostatin action, resulting in inhibition of other hormones and enzymes. These patients present with steatorrhea, diabetes and gall stones
4. Vasoactive intestinal peptide tumors or VIPomas develop diarrhea, low potassium and low acid output
5. Treatment includes surgical removal of the tumors and use of several anti-tumor agents. Streptozocin decreases tumor mass. Other types of tumors may be controlled by a somatostatin analogue

Question 102

Discuss the exocrine dysfunction of the pancreas

Answer 102

1. Pancreatic exocrine insufficiency is due to the reduction in available pancreatic enzymes to aid in digestion. The patient suffers from diarrhea, malabsorption and malnutrition. These individuals need enzyme replacement and the nutritional supplements
2. Cystic fibrosis is a hereditary disease that disturbs the exocrine function of the pancreas, as well as the functioning of the respiratory system, the sweat glands and the reproductive system. Mucus production is altered, leading to thickened secretions of mucus. These children suffer from pancreatic insufficiency, respiratory disease and other abnormalities. Testing for electrolytes in the sweat of these individuals show increased sodium and chloride; DNA can also be tested

Question 103

Describe the anatomy of the liver

Answer 103

1. The liver, located in the right upper quadrant of the abdomen, is divided into a large right lobe and a smaller left lobe. Each lobe is further divided into hepatic lobules, composed of six hepatic cells. Each of the lobules is accompanied by the portal triad, consisting of a vein, an artery and a bile duct
2. Interspersed between these cells are sinusoids lined with Kupffer cells. The Kupffer cells are responsible for removing substances from the blood, such as old red blood cells or debris
3. Blood is supplied through the portal vein and the portal artery. Blood is drained through the hepatic veins

Question 104

Discuss the function of the liver in digesting fat

Answer 104

1. The liver functions to form bile and to participate in metabolism, coagulation, detoxification and storage of vitamins. Bile is used to aid in the digestion of fats. It is composed of bile acids, bile pigments, bilirubin and other substances. Bile acids, which are formed from cholesterol, become bile salts in the liver. Bile pigments are a breakdown product of red blood cells. Bilirubin, one of the bile pigments is released into the blood. Bilirubin, when joined or conjugated with glucuronic acid is excreted in bile
2. The bile drains into the hepatic ducts and joins the biliary duct system to deliver its contents to the small intestine

Question 105

Discuss other functions of the liver

Answer 105

Additional functions of the liver include:

1. The liver aids in carbohydrate and protein metabolism
2. It stores, releases and synthesizes glucose, depending on the needs of the body
3. It also metabolizes amino acids, synthesizes protein, metabolizes certain hormones and processes digested fat
4. The liver synthesizes the essential factors for both clotting and anti coagulating the blood
5. The liver cells accomplish detoxification by making toxins more water soluble so they can be disposed of by the body more easily
6. The liver is a reservoir for a number of vitamins, including riboflavin, vitamin D, vitamin K and vitamin E

Question 106

Discuss cirrhosis of the liver

Answer 106

1. Cirrhosis of the liver results from the liver’s attempts to repair and regenerate after an injury. The resulting inflammation, scarring and anatomical rearrangement leads to liver impairment. One of the major causes of cirrhosis is relegated to alcohol. The pathology is related to an enlarged liver with fatty infiltrates
2. Another form of cirrhosis results from bile duct injuries, such as primary biliary cirrhosis. The disease is related to cholestasis, causing fibrosis, inflammation and cell death
3. Postnecrotic cirrhosis follows a severe injury to the liver from infections, hepatotoxins or metabolic diseases
4. Symptoms may include pain, anorexia, jaundice or bruising. Diagnosis is established by tissue specimen
5. Those with cirrhosis may develop portal hypertension leading to varices, hepatic encephalopathy, hepatorenal syndrome or ascites. These individuals are also at risk of developing liver cancer

Question 107

Discuss some other complications of cirrhosis of the liver

Answer 107

1. The hepatorenal syndrome results in kidney failure in individuals with liver disease without evidence of other organic disease involving the kidney. There is gradual renal failure, with decreasing urine output, electrolyte abnormalities, and mental impairment. The prognosis is grim
2. Hepatic encephalopathy results in mental dysfunction in patients with liver disease. This can progress to coma. The cause is uncertain, but may be related to ammonia accumulation. Controlling gastrointestinal bleeding is important, since blood in the gut may increase ammonia levels. Lactulose may be given to bind ammonia in the gut and reducing its absorption

Question 108

Discuss portal hypertension

Answer 108

1. Portal hypertension is caused when the portal circulation encounters resistance, as in cirrhosis. This results in the shunting of blood through other systems. The excess pressure placed on other circulatory elements results in esophageal and gastric varices, splenomegaly, and hemorrhoids
2. To ascertain elevated pressures in the portal circulation, measurements must be taken to document a pressure gradient in the portal vein
3. To relieve the pressure, procedures are instituted to shunt blood away from the areas under pressure. These interventions include: portacaval shunts, splenorenal shunts, mesocaval shunts and TIPS or Transjugular intrahepatic portosystemic shunts

Question 109

Discuss hepatitis A and B

Answer 109

1. Hepatitis A is a viral disease that is spread by fecal-oral contamination. Although often asymptomatic, patients can present with fever, jaundice, nausea, pain and an enlarged liver. Most have no complications, but some develop cholestatic jaundice. There is a vaccine available for use. Those exposed should be given immune globulin
2. Hepatitis B is spread via blood, semen or saliva. Patients develop a non-specific illness, followed by jaundice. Patients develop pain, nausea, fever, jaundice and enlarged livers. Complications may include chronic hepatitis, cirrhosis and liver failure. There is a vaccine available. Interferon can be used to reduce inflammation and aid in clearance of the virus

Question 110

Discuss hepatitis C, D and E

Answer 110

1. Hepatitis C is a blood borne virus that causes chronic disease in roughly 90% of those infected. 20% of patients develop cirrhosis. Some develop cryoglobulinemia, which is associated with kidney disease and a lower leg rash. Treatment requires the use of interferon, which inhibits viral replication and aids in clearing the virus from liver cells
2. Hepatitis D is a virus only infects individuals with hepatitis B. HDV occurs as a co-infection with hepatitis B, and is eliminated with the hepatitis B infection. As a superinfection, however, HDV increases the severity of hepatitis B. Interferon has been used
3. Hepatitis E is spread by the fecal-oral route. It is prevalent in poorer regions and causes acute disease

Question 111

Define alcoholic hepatitis, drug-induced hepatitis and non-alcoholic stetohepatitis

Answer 111

1. Alcoholic hepatitis is inflammation related to the ingestion of alcohol. Patients present with abdominal pain, fever, vomiting, enlarged liver and anorexia. This appears to be a precursor of cirrhosis
2. Drug-induced hepatitis is inflammation related to a drug exposure. This reaction can be dose-dependent, idiosyncratic or cholestatic. Some patients may have no symptoms, others may become very sick. Tylenol overdoses can cause fulminant hepatic failure and require treatment with N-acetylcysteine
3. Non-alcoholic steatohepatitis is inflammation of the liver related to increased fatty deposits. It may be related to weight and diabetes. It can progress to cirrhosis

Question 112

Discuss liver cancer

Answer 112

1. Liver cancer can involve the liver cells or the bile duct cells. Those with an increased risk of developing liver cancer have cirrhosis, hepatitis B or C and exposure to certain toxins. It commonly spreads to the lungs and peritoneum. Metastatic disease is common in the liver, originating from lung, breast, or gastrointestinal sites
2. Most patients present with advanced disease, complaining of pain and weight loss. Diagnosis is accomplished by scanning and biopsy. Alpha fetoprotein may also be elevated. For those with limited disease, removal of the tumor may be used. Chemotherapy may treat pain; obstruction may need to be treated with stent placement

Question 113

Discuss Wilson’s disease and hemochromatosis

Answer 113

1. Wilson’s disease is a hereditary disease that results in copper build up in the liver, as well as other organs such as the brain or kidney. In the organs with copper deposits, the tissue is destroyed, causing organ failure. A characteristic Kayser-Fleischer ring may be detected as a brown ring around the eye. Treatment requires use of D-Penicillamine. All family members need to be evaluated for the presence of the disease
2. Hemochromatosis is a hereditary disease in which iron accumulates in tissue such as the liver, joints, heart and skin. Patients complain of abdominal pain, joint pain, weakness, and skin discoloration. These patients are at an increased risk of Hepatocellular carcinoma. Treatment requires phlebotomy to remove iron from the body

Question 114

Discuss the group of porphyria diseases

Answer 114

1. Porphyria leads to an excess of porphyrins or related substances because of a defect in heme synthesis. The hepatic porphyrias include acute intermittent porphyria, hereditary coproporphyria, variegate porphyria, and porphyria cutanea tarda or PCT. PCT is somewhat different in that there are no abdominal or neurologic symptoms. Instead patients develop skin lesions, excess hair and some hepatic abnormalities. This disease can be either inherited or acquired. The other listed diseases may present with abdominal pain and neurologic symptoms
2. Another porphyria disease is protoporphyria. Patients are sensitive to light and may have liver disease. Cholestyramine may control the liver disease

Question 115

List some causes of gastrointestinal bleeding

Answer 115

Gastrointestinal bleeding can occur anywhere along the gastrointestinal tract. It can be minimal and intermittent to life-threatening hemorrhage. Some cause of gastrointestinal causes include:
1. Peptic ulcer disease is the most common cause of gastrointestinal bleeding. This refers to an ulcer in the stomach or duodenum
2. Esophageal varices are a widening of the blood vessels in the lowe part of the esophagus and sometimes in the upper part of the stomach
3. Mallory-Weiss tears are lacerations in the esophageal mucosa from vomiting
4. Vascular malformations are abnormal collections of blood vessels that are prone to bleeding
5. Meckel’s diverticulum is a vestige of fetal tissue in the small intestine
6. Diverticulosis results in Outpouchings of the large intestine that disrupts a blood vessel
7. Angiodysplasia refers to stretched and distorted vessels in the large intestine resulting from aging
8. Hemorrhoids are swollen veins in the lower part of the rectum or anus
9. Neoplasia can occur anywhere along the tract and cause bleeding
10. Esophagitis/Gastritis/Colitis is inflammation of the bowel mucosa
11. Intussusception is the telescoping of one section of intestine into another
12. Obstruction causes complete blockage of the bowel
13. Cancer anywhere in the gastrointestinal tract can cause bleeding

Question 116

Define: Esophagus, UES, LES, peristalsis, dysphagia, odynophagia, esophageal varices, Zenker’s diverticulum, stricture, esophagitis, Mallory-Weiss tear, achalasia, diffuse esophageal spasm, Barrett’s esophagus, diverticula, and nutcracker esophagus

Answer 116

1. The esophagus is a muscular tube that connects the mouth to the stomach
2. UES or the upper esophageal sphincter is the upper end of the esophagus
3. LES or the lower esophageal sphincter is where the esophagus joins the stomach
4. Peristalsis describes the rhythmic, coordinated muscular contractions of the gastrointestinal tract
5. Dysphagia is the symptom of difficulty swallowing
6. Odynophagia is the symptoms of painful swallowing
7. Esophageal varices are dilated, distended vessels in the esophageal wall
8. Zenker’s diverticulum is an esophageal diverticulum or outpouching that is caused by UES dysfunction
9. Esophagitis is an inflammation of the mucosal lining
10. Mallory-Weiss tear is a laceration in the esophageal lining
11. Achalasia is a dilation of the esophagus from abnormal peristalsis and/or high LES pressure
12. Diffuse esophageal spasm is chaotic, simultaneous contractures of the esophageal musculature
13. Barrett’s esophagus occurs with the replacement of normal squamous epithelial cells by non-squamous cells in the esophagus
14. Nutcracker esophagus results from an increase in the amplitude of peristaltic contractions

Question 117

Define chyme, dyspepsia, Helicobacter, Linitis plastica, Pernicious anemia, gastric polyp, stress ulcers, hypertrophic pyloric stenosis, rugae, and parietal cells

Answer 117

1. Chyme is a combination of food with stomach secretions
2. Dyspepsia is non-specific epigastric pain or nausea
3. Helicobacter pylori are gram negative organisms associated with peptic ulcer disease
4. Linitis plastica is called leather bottle stomach, a diffuse submucosal stomach cancer that causes fibrosis
5. Pernicious anemia is a vitamin B12 deficiency due to lack of intrinsic factor
6. Gastric polyp is an uncommon stomach lesion that protrudes into the stomach
7. Stress ulcers are gastric ulcers associated with severe stresses, such as illnesses and burns
8. Hypertrophic pyloric stenosis occurs in infants and is more common in males. The pyloric sphincter resists passage of food to the intestines. This usually requires surgery
9. Rugae are wrinkles in the stomach surface to allow for expansion
10. Parietal cells are responsible for releasing intrinsic factor for vitamin B12 absorption

Question 118

Define: Plicae circulares, volvulus, borborygmi, lactase deficiency, abetalipoproteinemia, intrinsic factor, crypts of Lieberkuhn, Peyer’s patches and steatorrhea

Answer 118

1. Plicae circulares are the arrangement of the mucosa and submucosa that provides increased surface area in the small intestines
2. Volvulus occurs when the bowel twists around itself. It can cause ischemia
3. Intussusception occurs when part of the intestine telescopes up the lumen of the adjacent intestine
4. Borborygmi refers to excessively loud bowel sounds
5. Lactase deficiency occurs when the small intestinal lining lacks the enzyme lactase, causing diarrhea and malabsorption with lactose products
6. Abetalipoproteinemia occurs in individuals that lack betalipoproteins, which leads to build up of fat in the small intestines. This causes malabsorption
7. Intrinsic factor is produced by the gastric parietal cell and allows for absorption of vitamin B12
8. Crypts of Lieberkuhn are the area adjacent to the small intestinal villi responsible for replenishing the columnar epithelium
9. Peyer’s patches are lymph collection/nodes in the ileum
10. Steatorrhea is bulky, malodorous stool with excess fat content

Question 119

Define hemorrhoids, fecal impaction, encopresis, anorectal abscess, anorectal fistula, anal fissure, and rectal prolapse

Answer 119

1. Hemorrhoids are swollen blood vessels in the anal area. Internal hemorrhoids occur above the internal sphincter; external hemorrhoids below. Those from the internal area drain into the portal system, so diseases that lead to portal hypertension can lead to internal hemorrhoids
2. Fecal impaction occurs when fecal material is not eliminated appropriately. The retained stool forms a solid collection that impedes further passage of stool
3. Encopresis is caused when chronic constipation leads to involuntary stool leakage
4. Anorectal abscess is a collection of pus in the anorectal area
5. Anorectal fistula is an abnormal formation of an opening in the peri-anal area, usually caused by an abscess
6. Rectal prolapse occurs when rectal tissue protrudes through the anus

Question 120

Define jaundice, biliary colic, choledocholithiasis, acalculous cholecystitis, emphysematous cholecystitis, acute calculous cholecystitis, gallstone ileus and cholangitis

Answer 120

1. Jaundice results from deposits of bile pigments in certain tissues causing a yellowish discoloration
2. Biliary colic is pain caused by biliary tract stones
3. Choledocholithiasis is the term meaning that gallstones are located in the common bile duct or the hepatic duct
4. Acalculous cholecystitis presents with cystitis in the absence of gallstones
5. Emphysematous cholecystitis refers to cholecystitis that demonstrates gas in the wall of the gallbladder or biliary ducts
6. Acute calculous cholecystitis is an inflammation of the gallbladder because a gallstone is obstructing the cystic duct
7. Gallstone ileus is intestinal obstruction caused by a gallstone in the ileum
8. Cholangitis 9s a bacterial infection of the biliary ducts caused by obstruction

Question 121

Define: duct of Santorini, secretin, cholecystokinin-pancreozymin, Grey’s turner’s sign, Cullen’s sign, pseudocyst, Whipple operation, pancreatic rest, pancreatic divisum, annular pancreas, and Schwachman-Diamond syndrome

Answer 121

1. Duct of Santorini is an extra pancreatic duct that most people have, along with the duct of Wirsung
2. Secretin is a pancreatic enzyme high in bicarbonate that is stimulated by acidic stomach products
3. Cholecystokinin-pancreozymin is an enzyme released by the duodenum that is stimulated by proteins and fats. It acts on the pancreas to stimulate pancreatic enzyme release
4. Grey Turner’s sign is the appearance of a bluish tinge to the flanks secondary to bleeding from acute pancreatitis
5. Cullen’s sign is the appearance of a bluish tinge around the umbilicus secondary to bleeding from acute pancreatitis
6. Pseudocyst is a collection of pancreatic debris surrounded by granulation tissue but without a true epithelial layer
7. Whipple operation is a pancreaticoduodenectomy to treat pancreatic cancer or other diseases
8. Pancreatic rest refers to pancreatic tissue in sites other than the pancreas
9. Pancreatic divisum results when embryonic pancreatic tissue does not combine, causing two separate pancreatic ducts
10. Annular pancreas refers to a condition where embryonic tissue fails to combine and a portion of the pancreas surrounds the duodenum
11. Schwachman-Diamond syndrome is an inherited disorder involving pancreatic insufficiency, neutropenia and growth problems

Question 122

Define Glisson’s capsule, glycogenesis, glycogenolysis, gluconeogenesis, Caput medusae, ascites, hepatitis, fulminant hepatic failure, alpha 1-antitrypsin deficiency, and biliary atresia

Answer 122

1. Glisson’s capsule is the connective tissue covering enveloping the liver
2. Glycogenesis is the process the liver employs to convert glucose to glycogen for storage
3. Glycogenolysis is the process the liver undertakes to convert glycogen to glucose
4. Gluconeogenesis is the process the liver uses to synthesize glucose
5. Caput medusae is caused by portal hypertension leading to dilated vessels around the umbilicus
6. Ascites is the accumulation of fluid in the abdominal cavity
7. Hepatitis is inflammation of the liver parenchyma caused by infection, toxins, or immune reactions
8. Fulminant hepatic failure is massive hepatic cell death due to an insult, such as an infection or an exposure to a toxin
9. Alpha 1 antitrypsin or AAT deficiency is an inherited disease that causes a lack in the AAT enzyme, which can lead to liver and lung disease
10. Biliary atresia results in scarring of the biliary duct system causing cholestasis and liver damage

Question 123

Discuss important pre- and post- procedure patient education for GI procedures and post-education for colonoscopy and Esophagogastroduodenoscopy

Answer 123

1. Patient education in preparation for GI procedures is similar, regardless of the procedure. The patient should clearly understand the name and purpose of the procedure, the risks and benefits, any food restrictions (red meat, red dye) and medication restrictions (such as blood thinners and iron preparations), the GI prep required, the need to be NPO for 6 to 8 hours prior to the procedure, the need to arrange for transportation because of post-sedation grogginess, the type of sedation the patient will receive, the need for an IV during the procedure, and possible complications or adverse reactions. Post procedure education may vary, depending on the risks associated with the procedure
2. Colonoscopy
   
   • Patient can resume normal diet. Patient must immediately notify MD for abdominal distention, severe abdominal pain, increased fever, vomiting and rectal bleeding (>30mL)
3. Esophagogastroduodenoscopy
   - Food and drink restricted until swallowing reflex intact. Sore throat may persist for a few days. Patient must immediately notify MD for increased fever, chills, tarry or bloody stools, dysphagia, increasing throat pain, chest pain, abdominal distention and pain

Question 124

Discuss important post-procedure education for endoscopic retrograde cholangiopancreatography, and Percutaneous endoscopic gastrostomy

Answer 124

1. Endoscopic retrograde cholangiopancreatography
   
   • Food and drink restricted until swallowing reflex intact. Sore throat may persist for a few days. Patient must immediately notify MD for increased fever, chills, tarry or bloody stools, dysphagia, increasing throat pain, chest pain, abdominal distention and pain. Patient should be advised of risk of pancreatitis
2. Percutaneous endoscopic gastrostomy
   - Patient must meet with a dietician and have a clear understanding of feeding procedures and adequate nutrition. Patient/family must learn would care, skin care, and should notify the MD immediately for sings of infection (redness, swelling, pain) or displacement of the tube. The patient/family must learn how to care for the PEG tube and should practice carrying out feedings under supervision

Question 125

Discuss indications and recommendations for colonoscopy

Answer 125

Colonoscopy, examination of the colon with a flexible four-foot colonoscope with a light source and video camera at its tip, is indicated for:

1. Periodic routine screening for colorectal cancer and colorectal polyps at age 45 to 50 and every 10 years until age 75. Between age 76 and 85, screening recommendations depend on general condition or risk factors. Screening is not recommended for those over age 85
2. History of colorectal cancer or polyps. Frequency usually increased to every 3 years if precancerous polyps removed
3. History of blood in the stool, which may indicate colon cancer
4. History of change in bowel habits, such as constipation or diarrhea, abdominal pain
5. History of acute/chronic iron-deficiency anemia, which may be related to blood loss
6. History of ulcerative colitis or Crohn’s disease, which increases risk of colon cancer
7. History of family genetic conditions associated with colon cancer, such as hereditary non-polyposis colorectal cancer

Question 126

Outline preventative measures for colon cancer

Answer 126

Prevention measures for colon cancer include:

1. Have regular screenings for colon cancer every year with home stool tests, flexible sigmoidoscopy every 5 years, and colonoscopy every 10 years, starting at age 45 or earlier and more frequent if risk factors present (Crohn’s disease, family history of colorectal cancer, hereditary conditions, type 2 diabetes, ulcerative colitis, alcoholism)
2. Avoid obesity and maintain weight within normal range
3. Stop smoking or don’t start
4. Remain physically active, ideally for at least 30 minutes daily
5. Avoid red meat and processed meats, limit to 3 servings or fewer per week
6. Eat a diet with ample fruits, vegetables, and whole grains
7. Avoid simple carbohydrates (sugar, flour)
8. Ensure adequate vitamins and minerals, especially vitamin D and calcium
9. Limit intake of alcohol to one drink daily for females and 2 drinks daily for males

Question 127

Discuss important education regarding substance use and its effect on gastrointestinal health

Answer 127

Substance abuse can have profound negative effects on the gastrointestinal system:

1. Alcohol: Increases acidity in the stomach, leading to stomach ulcers and GI bleeding. Liver becomes scarred, and cirrhosis develops because of the need to metabolize large amounts of alcohol
2. Opiates/Opioids: Chronic constipation caused by the drugs may lead to narcotic bowel syndrome with chronic abdominal distention, nausea, vomiting and constipation. Drugs that include acetaminophen can result in liver damage and lead to liver failure
3. Tobacco: Increases the risk of development of peptic ulcers and Crohn’s disease. Also increases risk of cancer
4. Cocaine: Blood clots associated with use may cause intestinal necrosis. Also increases risks of intestinal and gastric perforations and ulcerations as well as liver damage
5. Methamphetamine: Tooth decay, loss of teeth, and impaired blood flow to the gums results in “meth mouth” and impaired ability to chew. Constipation or diarrhea are common. The liver and pancreas functions may become impaired, affecting digestion. Absorption of nutrients is impaired. Intestinal infarction may occur

Question 128

Outline the key parts and functions of the endoscope

Answer 128

The endoscope is a flexible or rigid device used to view internal body parts, such as the esophagus, stomach and colon. The endoscope contains a number of different channels so that instruments, air, or water can be passed and suctioning performed. A video lens and light are at the distal end, and video images are transmitted to a monitor. Some endoscopes have an eyepiece attached to the scope. Various types of endoscopes are available, including bronchoscope and colonoscope, and they come in different sizes, lengths and flexibility

Question 129

Describe the endoscope

Answer 129

1. All endoscopes contain the following:
   
   • an insertion tube that is flexible and has channels for biopsy
   • a cord that is attached to the light source
   • Fiberoptic system for promulgating visual access/video systems have camera access for television
2. The control center which contains:
   
   • the lens
   • controls for moving the lens
   • control valves
   • cables for motion control
   • channels for controlling water and air manipulation
   • biopsy channel for access via snares, forceps, brushes
3. This procedure allows for visualization and biopsy of the gastrointestinal tract. It provides diagnosis and also therapy
4. There are a number of different endoscopes available, including the flexible endoscope, the anaoscope, the proctosigmoidoscope, the flexible sigmoidoscope and the colonoscope

Question 130

Describe anoscopy and the proctosigmoidoscopy

Answer 130

1. The anoscope aids in evaluating rectal bleeding. It is a rigid tube with a slot at the ends. This is where the mucosal surface can be viewed. Evaluation of the area is done prior to inserting the scope. The patient reclines on the left with knee drawn to the chest as the lubricated anoscope is advanced. It should be lubricated and warm
2. The proctosigmoidoscope is a rigid tube with a light source used for evaluating bleeding, diarrhea, pain or extraction of a foreign body. The warmed tube is inserted to the desired point and then slowly retracted, allowing the operator to examine the mucosal surface. Complications may include perforation and bleeding

Question 131

Describe flexible sigmoidoscopy

Answer 131

1. The flexible sigmoidoscope is more commonly used than the rigid device and is used to evaluate the rectum, the sigmoid colon and the distal end of the descending colon. The lubricated instrument is advanced up the descending colon. As the scope is slowly drawn back, the operator scrutinizes the lining of the intestines. During the procedure the operator may take biopsies, remove polyps or administer therapies such as electrocautery
2. The nurse must monitor vital signs, assess the comfort of the patient and evaluate for complications
3. Complications may include perforations and bleeding. If no complications occur, the patient may resume normal activities and a normal diet

Question 132

Describe colonoscopy

Answer 132

1. The colonoscope evaluates the gastrointestinal lining of the whole length of the large intestine. The operator advances the lubricated instrument through the large intestine. As the scope is withdrawn, the operator evaluates the lining for abnormalities. The colonoscope can also enable the operator to take biopsies, to remove polyps or to administer therapies
2. This procedure commonly requires sedation and anesthesia. In addition, medications to control motility may be administered
3. The nurse must appropriately and timely monitor vital signs and oxygenation and evaluate the status of the patient. The nurse may also need to help position the patient or to press the abdomen to help the operator maneuver the scope
4. Complications include perforation and bleeding

Question 133

Explain the M2A capsule endoscopic procedure

Answer 133

1. M2A Capsule endoscopy is a relatively new technique that allows for visualization of the small bowel. A special capsule with appropriate technology can transmit images to a receiver. Once the capsule is activated, the patient swallows the capsule. As the capsule traverses the gastrointestinal tract, it transmits images to special sensors affixed to the outside of the patient’s abdomen. A recording device is worn by the patient to store the images
2. The patient, after not eating for six hours, swallows the capsule and cannot drink for 2 hours or eat for four hours. The process of collecting images takes approximately 8 hours, at which time the device is removed from the patient
3. This procedure cannot be used in patients with obstructions or electrical cardiac devices
4. The method offers an effective, non-invasive way to visualize the small intestine. It cannot obtain tissue or institute therapeutic maneuvers however

Question 134

Describe endoscopy of an ostomy site

Answer 134

1. Patients with an ostomy site may need endoscopic evaluation. After draping the abdominal area around the ostomy, careful removal of the ostomy should be accomplished from top to bottom
2. The patient should be supine, and the operator needs to insert the endoscope from a right angle to the abdominal wall. The usual precautions concerning vital signs and oxygenation need to be taken. In addition, care should be taken to provide a tight seal between the ostomy site and the scope
3. After cleaning the area, the patient will need new collection apparatus

Question 135

Discuss videoendoscopy and endoscopic ultrasonography

Answer 135

1. Videoendoscopy uses technology to transmit signals to a video device to display images. These video images can be seen by the entire staff and the patient. The equipment has the capability of generating photographs. The endoscope is similar to other endoscopes
2. Endoscopic ultrasonography incorporates ultrasound technology to visualize the gastrointestinal tract. The endoscope has ultrasound equipment in the tip. This procedure offers better image resolution and allows for assessing wall thickness of the various parts of the gastrointestinal tract. Some intra-abdominal organs can be seen, such as the pancreas and the gallbladder

Question 136

Describe endoscopic biopsy

Answer 136

1. Endoscopic biopsy is used to obtained tissue for diagnostic purposes or to assess therapy. The scope has a biopsy channel that allows appropriate forceps to be used. At the direction of the physician, the nurse opens and closes the forceps, and the tissue sample is removed. Usually multiple samples are taken to increase the diagnostic yield
2. Biopsy usually is fairly superficial. With rectal suction biopsy, the tissue is suctioned and then biopsied. This allows for deeper penetration
3. The sample is evaluated by a pathologist. An answer can be obtained quickly, when appropriate, with a frozen section
4. There are disposable forceps available. Those that are re-usable must be cleaned and sterilized
5. Complications may include perforation and bleeding

Question 137

Discuss fine-needle aspiration for pancreatic disease

Answer 137

1. Fine-needle aspiration of the pancreas can be accomplished through the abdominal wall under ultrasound guidance or CT guidance. This is a fairly accurate way to diagnose pancreatic cancer. Complications may include infection
2. Diagnosis of pancreatic cancer can be accomplished with endoscopic ultrasound-guided fine needle aspiration. The needle is passed through the biopsy channel and it is directed to the targeted tissue by ultrasound. The recovered material is placed on a slide for evaluation. This procedure is helpful in diagnosing and in staging of cancers

Question 138

Describe capsule endoscopy

Answer 138

Capsule endoscopy is accomplished by having the patient swallow a video capsule to visualize the bowels. The camera in the capsule sends pictures to sensors attached to the patient’s body. There is a recording device attached to the patient, as well. The device enables evaluation of the small bowel

1. Once the capsule is swallowed the patient must refrain from eating for two hours. At four hours the patient can eat something light. Prior to the procedure, the patient must have nothing by mouth from midnight on
2. After 8 hours, the patient reports back with the sensors and the recorder
3. The capsule will be eliminated with stool, although it can infrequently cause obstructive symptoms. Surgery may be needed to remove the capsule
4. The patient must avoid MRI studies until the capsule is eliminated

Question 139

Discuss obtaining samples for cytology

Answer 139

1. Brush cytology involves passing a small brush through the biopsy channel. The brush abrades the targeted tissue, is withdrawn and the material is applied to a slide. Sometimes the tips of the brushes are sent to the laboratory, as well
2. For washings, a special trap is affixed to the suction port. The endoscope allows for the suctioning of the tissue. The trap is sent for examination. The washings for an esophageal specimen can be applied via a nasogastric tube. For a gastric specimen, gastric lavage is required. For a pancreatic sample, saline is sent into the duct and aspirated back with a syringe. In the colon, after careful preparation , saline is instilled and then aspirated several minutes later

Question 140

List some indications, contraindications and possible adverse effects for Esophagogastroduodenoscopy or EGD

Answer 140

Indications:
1. Dysphagia
2. Odynophagia
3. Unremitting symptoms of reflux
4. Unexplained vomiting
5. Bleeding
6. Abnormalities noted by other studies, such as x-rays
7. Evaluation for cancer
8. Evaluation for response to therapy

Contraindications:
1. Cardiovascular instability or shock
2. Seizures
3. Recent cardiac or pulmonary event
4. Cervical arthritis, if severe
5. Non-compliance with NPO order

Adverse effects:
1. Respiratory distress
2. Cardiac distress
3. Vasovagal reaction
4. Aspiration
5. Perforation
6. Allergic reaction

Question 141

Describe the EGD procedure

Answer 141

1. Endoscopy is performed with the patient lying on the left side with the chin tucked to the midline of the chest. The lubricated scope is passed slowly through the various gastrointestinal structures, allowing time for clearing secretions and visualization. As the endoscope approaches the small bowel, the patient may report symptoms of pain or fullness. Duodenal spasm may impinge on visualization, requiring administration of a muscle relaxant
2. Pediatric patients are more likely to experience respiratory symptoms during the initial phase of the endoscopy. These symptoms may be alleviated by lifting the jaw forward
3. Throughout the endoscopy, the patient’s airway should be guarded by removing secretions or other potential obstructions
4. Once the procedure is completed, the patient may attempt to take fluids when the gag reflex has returned

Question 142

Describe the endoscopic retrograde cholangiopancreatography (ERCP) procedure

Answer 142

1. ERCP Procedure
   - After the equipment has been fully tested, a side-viewing endoscope is used on the patient, who may be prone. If the patient begins on the left side, he or she must be turned to the prone position before the following step. Once the operator views the ampulla of Vater, a plastic cannula is threaded through the instrument to enter the opening in the duodenum. The cannula injects dye into the pancreatic duct or the biliary duct, depending on the operator’s maneuvering. X-rays are taken, allowing depiction of the ducts to evaluate anatomy. The endoscope can also obtain tissue by biopsy or brushings
2. Complications of this procedure are pancreatitis and infection, along with the risk of bleeding and perforation. Some patients have an allergic reaction to the dye
3. Indications for an ERCP include evaluation for cancer, unknown cause of pancreatitis, common bile duct stones, or unknown abdominal pain

Question 143

Discuss sphincterotomy of the sphincter of Oddi

Answer 143

1. Sphincterotomy is performed via ERCP to cut the muscles of the sphincter of Oddi. This may be necessary to help pass gallstones or to relieve obstructions. A side-viewing scope with appropriate cannulas is inserted into the patient. The sphincterotome should be placed superficially and then placement should be checked with Radiographic evaluation. The sphincterotome is flexed and short burst of current are supplied
2. The passage of bile and blood signifies success, generally. The passage of stones may take longer because of edema from the procedure
3. Other equipment may be used to retrieve stones, if needed. A stent may need to be placed, as well

Question 144

Discuss ways to visualize the biliary tract

Answer 144

1. Biliary tract disease can be addressed by dilatation either by ERCP or by Percutaneous transhepatic cholangiography. If a stent is needed to overcome an obstruction, that can be placed, as well
2. A diagnostic ERCP is done to evaluate the problem and to delineate the anatomy. A guidewire is passed and then a silicone sprayed balloon. The balloon is inflated according to the manufacturer’s directions. The inflation can be repeated. Sometimes a stent can be placed after the inflations are completed
3. Pancreatitis is the most common complication. The bile ducts may sustain some injury, as well

Question 145

Discuss the different endoscopic variceal ligation procedures

Answer 145

1. Endoscopic variceal ligation or EVL involves placing bands or rings around the varix or hemorrhoid. Several instruments are available, and the manufacturer’s directions should be carefully followed. The varix or hemorrhoid is sucked into the ligating device and the ligature is placed around the tissue. The suction is then released
2. Although the band device is more expensive, it offers some advantages over the O-ring applicator, particularly the ability to perform multiple banding steps with one endoscopic insertion. Both procedures result in less pain for the patient and are less likely to cause strictures

Question 146

Discuss ablation of cancerous obstruction with a bipolar probe

Answer 146

Ablation of Cancerous Obstructions

1. A guidewire is passed through an endoscope with guidance by fluoroscopy, if possible. Then the endoscope is removed. Dilators may be needed to allow for passage of the probe to the distal area of the obstruction. Current is applied in a proximal pattern until the most proximal site is treated
2. Endoscopy is repeated to ascertain the effectiveness of therapy. The patient must be monitored afterwards and kept NPO. Some patients may complain of dysphagia for a day after the procedure
3. Another endoscopy is performed in two days to determine the efficacy of the treatment and to assess if another course of therapy is needed

Question 147

Discuss injection therapy in general

Answer 147

1. Injection therapy is used to treat esophageal varices that are bleeding. The operator injects a substance in or around a targeted variceal abnormality to stop any bleeding. The endoscopist passes an endoscope, preferably double channeled to allow for suction, and then introduces the needle assembly. The patient must be medically stable and cooperative. Emergency therapy should be available at all times
2. When the bleeding site is located, the needle is injected into the targeted site. The chosen agent is injected at the physician’s direction. Once completed, the needle assembly can be discarded according to the sharps protocol

Question 148

Discuss the indications for removal of foreign bodies in the gastrointestinal tract

Answer 148

1. Removal of foreign bodies can be accomplished with endoscopy or surgery. In the vast majority of cases, foreign bodies pass through the gastrointestinal tract without intervention, however. Foreign bodies tend to get lodged where there is narrowing, like the LES
2. Removal must move forward for foreign bodies that are sharp to prevent bleeding or perforation. Also, batteries need to be removed quickly to prevent caustic injury from the contents of the battery. In the case of drug packet foreign bodies, surgery is the best treatment to avoid overdose and/or death
3. Foreign bodies in the stomach that are larger than 2 centimeters need to be acted upon, as do any stomach foreign bodies that do not pass within 2 weeks. Similarly, foreign bodies that persist in the duodenum for 6 days need to be removed

Question 149

Describe the methods used to remove foreign bodies from the gastrointestinal tract

Answer 149

1. To endoscopically remove a foreign body from the esophagus, the operator must have a firm hold on the object. This will ensure that the object is not inappropriately dropped where it can interfere with respiration. If the object is sharp, the sharpened end should be pointed away from the direction of removal. Sometimes an Overtube or a hood is placed over the endoscope to protect the mucosal surface of the esophagus, as well as the airway
2. Impacted food can be pushed into the stomach by using dilators, if needed
3. For objects that lodge in the large intestine can be removed by colonoscopy, using forceps or retrieval nets. Objects in the sigmoid or rectal area can be removed by an appropriate scope, such as a sigmoidoscope, a proctoscope or an anoscope

Question 150

Outline the appropriate processing and handling for the following gastrointestinal specimens: Gastric aspirate, duodenal aspirate, gastric biopsy specimens, and rectal biopsy specimens

Answer 150

Processing and handling for gastrointestinal specimens includes:
1. Gastric aspirate: Place aspirate (at least 1mL) in gastric aspirate tube with bicarbonate or specimen cup for transportation to the laboratory. If no bicarbonate is in the container, the sample should be neutralized with bicarbonate within 30 minutes

2. Duodenal aspirate: Place specimen (at least 2mL) in sterile centrifuge tube and transport to the laboratory immediately for examination within 60 minutes of collection
3. Gastric and rectal biopsy specimens: Tissue specimen is placed in a sterile container with a preservative, such as formalin and labeled with identifying informant and the location from which the sample was obtained. The specimen undergoes a gross examination as well as microscopic. The sample may be preserved in paragon wax and cut into slices which are placed on a slide and examined microscopically. If results are required quickly (such as when the surgeon is waiting to continue surgery), a frozen section may be done

Question 151

Outline the appropriate processing and handling for the following gastrointestinal specimens: Fecal specimens

Answer 151

Fecal samples should be directly collected or placed in a clean container and further processed according to the type of testing that will be carried out

1. Culture: Place in liquid transport media with preservative, such as orange Cary-Blair container, and test within 14 days. Unpreserved stool must be tested within 2 hours
2. O&P (Giardia and Cryptosporidium): Place is liquid transport media (as above) and test within 14 days. Unpreserved stool may be refrigerated at 2 degrees to 8 degrees Celsius but must be tested within 72 hours
3. O&P (other): Place in Parasep SF (green) containing preservative, such as Alcor Fix within 1 hour of collection for testing up to 9 months. May be stored at room temperature or under refrigeration. Unpreserved stool must be tested within 2 hours
4. WBC: Unpreserved stool specimen must be tested within 2 hours
5. Occult blood: Smear sample of stool onto card, which must be tested within 14 days
6. Clostridium difficile: Place Unpreserved semi-liquid/liquid stool in container and submit immediately for testing within 24 hours at room temperature or within 5 days if refrigerated at 2 degrees to 8 degrees Celsius
7. Rotavirus: Place Unpreserved specimen in container and submit immediately for testing

Question 152

Discuss the various probes used in non-endoscopic procedures

Answer 152

Probes are thin solid or flexible instruments or catheters used to explore or assess wounds, body cavities, and body organs. Various probes used in non-endoscopic procedures include:

1. Ultrasound probe: May help to identify problems in blood flow to the GI system, and may help in diagnosis of gallstones and liver disease, such as scarring indicating cirrhosis
2. Eyed probe: Has a small “eye” or opening at one end which can carry ligatures. This 6-inch probe can be used to help determine the size and depth of fistulas or cavities
3. Esophageal pH probe: A thin probe is inserted nasally and into the esophagus and attached to a monitor that continually assesses acidity, usually for a 24-hour period, to aid in the diagnosis of acid reflux. A 48-hour probe involves attaching a small monitor by catheter to the distal portion of the esophagus. This monitor sends acidity recordings wirelessly to a recorder worn on the body and automatically detaches and passes through the intestinal tract after 48 hours

Question 153

Discuss the use of ligature in the following non-endoscopic procedures: Rubber band ligation and LIFT procedure

Answer 153

The use of ligature in non-endoscopic procedures included:

1. Rubber band ligation: Used primarily for first - and second degree hemorrhoids and involves placing a band about the base of the hemorrhoid and leaving it in place to cut off the blood supply to the hemorrhoid. Over the next 7 days or so, the tissue sloughs off. While slight bleeding and mild discomfort is common, there is also a small risk of severe bleeding and sepsis
2. Ligation of intersphincteric fistula tract (LIFT): This method of ligation for fistula-in-ano is used primarily form trans-sphincteric fistulae and involves incision to identify the intersphincteric fistula tract, ligation and removal of the tract, curetting of the tract, and suturing at the external sphincter muscle. This procedure prevents fecal material from contaminating the tract and allows it to heal, preserving the sphincter. Success rates vary and range from 57% to 94% and some fistula recur, but are usually less severe

Question 154

Discuss equipment used in manometry

Answer 154

1. Esophageal manometry assesses pressures within the esophagus and evaluates motility and coordination of the muscular activity of the esophagus. This technique is useful if other disease causing the symptoms have been ruled out, if the information would add to the knowledge needed to treat the patient, and in placing pH probes
2. The instrument is a tube that includes a pressure transducer to reflect pressures as an audible and recordable signal. It also houses a water-perfumed catheter or a solid-state probe to measure the pressures and activities
3. Prior to using, the equipment must be checked and the patient evaluated. The catheter is inserted, and the patient is told to swallow to help the tube pass. Once the tube is in the stomach, appropriate measurements can be obtained
4. Afterwards, the catheters are rinsed with detergent, rinsed and dried, and sterilized via ethylene oxide. If a solid-state probe was used, this is subjected to high level disinfection alone

Question 155

Discuss manometry evaluation of the esophagus

Answer 155

1. To assess the LES, the catheter is pulled back through the LES. If done rapidly, the LES location can be determined. Pulling more slowly gives a fuller picture of the functioning of the LES. When the catheter enters the thoracic cavity, the tracing goes down; this is called the respiration inversion point
2. To assess the esophageal body, the catheter is stationed so that its ports are located throughout the length of the esophagus. The patient performs swallowing to allow the ports to assess the coordination and activity of the muscles of the esophagus. Normally, the movement is a coordinated and progressive wave of activity. Abnormalities in strength and coordination can be detected
3. To assess the UES, the manometric ports evaluate the pressure with swallowing

Question 156

Discuss provocative testing with manometry

Answer 156

1. Provocative testing is used to help determine the origin of chest pain, assuming heart disease has been ruled out
2. The Bernstein test uses a nasogastric tube or a manometric tube to drip alternating solutions of saline and dilute acid into the esophagus/ the patient is asked to indicate when pain occurs
3. Edrophonium testing also helps elucidate non-cardiac chest pain. After a manometric exam, a catheter is inserted; the catheter has several portals. Edrophonium a cholinesterase inhibitor, is altered with saline intravenously. The Edrophonium promotes muscle contractions. If this replicates the patient’s pain, it is a positive test

Question 157

Discuss how manometry is used in diagnosis of esophageal diseases

Answer 157

1. Manometry is used to diagnose achalasia, which results from loss of esophageal motility and increased LES tone. The instrument should be passed through the LES so that the sphincter tone and pressure can be determined. The LES may have insufficient relaxation or may have a very short period of relaxation
2. For diffuse esophageal spasm, the manometry reveals concomitant smooth muscle contractions towards the LES region
3. For nutcracker esophagus, the manometry reveals amplified contractions that may be prolonged. These patients are likely to have a reaction to Edrophonium
4. Manometry can also assess LES tension and other motility abnormalities. Diabetics for example, are prone to esophageal motility disorders
5. For esophageal reflux, patients may have some manometric abnormalities, but pH monitoring is more useful

Question 158

Discuss other uses of manometry

Answer 158

1. Gastroduodenal manometry is useful in assessing motility disorders in the stomach and small intestines. It can help in the diagnosis of gastroparesis and gastric arrhythmias
2. Small bowels can be evaluated for motility disorders or dumping syndromes. The manometric apparatus is inserted over a guidewire and is able to assess measurements at the antrum, the duodenum and the small bowel
3. The sphincter of Oddi can be evaluated for motility disorders, as well as stenosis. This can be done via ERCP. A catheter, equipped with manometry, is passed up the biliary tract, and the manometer is pulled back to assess pressures

Question 159

Discuss anorectal manometry

Answer 159

1. Anorectal manometry is useful in investigating, constipation, incontinence, connective tissue disease, Hirschsprung’s disease and Chagas’ disease. The instrument is composed of a balloon, and two sensors; one for the internal sphincter and one for the external sphincter. The balloon is inflated and then sphincter responses are assessed. Normally the internal sphincter should relax as the bowel distends; the external sphincter tightens
2. Some health practitioners have used anorectal manometry as a form of biofeedback for patients with incontinence problems due to other causes such as trauma or multiple sclerosis. The patient may be able to learn appropriate reactions to the stimulation from rectal distention

Question 160

Discuss liver biopsy procedures

Answer 160

1. Percutaneous liver biopsy can be done to diagnose liver disease and to stage cancers. If the patient is determined to be a good candidate, he/she should be educated and evaluated prior to procedure. An IV should be placed and vital signs documented. After the skin is carefully cleaned, the layers overlying the liver are anesthetized. A small incision is made and the needle, which is attached to a syringe, is inserted. The syringe has sterile saline for flushing the needle. Liver tissue is aspirated through the needle and then placed in saline or formalin
2. In some cases, the biopsy is guided by ultrasound or CT
3. After the procedure, the wound must be damped for 2 hours, accompanied by bed rest for six to eight hours. The patient must be monitored for bleeding, peritonitis, infection or other signs of complications

Question 161

Discuss some Radiographic studies of the gastrointestinal tract

Answer 161

1. Radiographic studies of the gastrointestinal tract are used to evaluate anatomy and to look for pathology. These tests are often better tolerated, but the diagnostic yield is not as good as endoscopic procedures
2. Barium sulfate is the commonly used contrast medium, allowing for x-ray and fluoroscopic studies. Since the barium may interfere with other kinds of studies, it should be done after those are completed
   
   • the patient should be advised that stools will be lighter colored, but this should be completed in a few days. It is important that the patient eliminate the barium so they do not develop constipation
3. Radiographs of the pancreas, the gallbladder and the biliary tree are done using an iodine-based contrast medium. Some patients are allergic to the medium

Question 162

Discuss some imaging studies to evaluate the biliary system

Answer 162

1. Magnetic Resonance Cholangiopancreatography evaluate the biliary system and the pancreatic ducts, avoiding and ERCP. The patient is given a contrast medium, gadolinium
2. Percutaneous transhepatic cholangiography visualizes the biliary system by passing a skinny needle through the liver until a bile duct is penetrated. Iodine contrast medium is then added so that the system can be evaluated
3. Abdominal ultrasound uses sound waves to visualize abdominal organs. A transducer traverses the patient’s abdomen, converting the reflected sound waves to images
4. Oral cholecystography studies the biliary system by having the patient ingest pills with contrast medium. 10-14 hours later, the films are taken

Question 163

Discuss some uses of scintigraphy in the gastrointestinal tract

Answer 163

1. Scintigraphy uses radioisotopes to assess anatomy and pathology
2. Hepatic scintigraphy is used to study the liver. The Kupffer cells absorb the radioisotope; abnormal structures without Kupffer cells are not visualized. It is used to assess metastatic disease, hepatocellular disease or other infiltrating diseases
3. Biliary scintigraphy introduces a radioisotope that is take up by liver cells and then passed into the bile system so that the biliary system can be visualized
   - gastric emptying can be assessed by using a radioisotope to label food that is ingested by the patient. The scanner follows the course of the labeled food
4. Scintigraphic scanning may be used to evaluate gastrointestinal bleeding. Labeled red blood cells are given to the patient and scanning follows their course through the circulatory system
   • this same technique can be used to label white blood cells to look for inflammation

Question 164

Discuss some secretion studies of the gastrointestinal tract

Answer 164

1. Pancreatic stimulation requires placement of a duodenal tube. The pancreas is stimulated by secretin and cholecystokinin. Secretions are evaluated to determine if there is exocrine insufficiency or other diseases
2. Gastric analysis requires that a tube be placed along the greater curvature and reaches the most dependent area of the stomach. Basal acid secretions are obtained and then secretions resulting from stimulation by the enzyme pentagastrin are measured. This can determine if there is too much acid, as in Zollinger-Ellison syndrome, or not enough acid as in achlorhydria
3. 24-hour pH monitoring allows for assessment of acid levels over a long period. This assesses esophageal reflux or evaluates chest pain. The pH probe is passed through the esophagus to just above the LES. The pH levels are recorded, as are patient symptoms and activities

Question 165

Some common liver function tests

Answer 165

1. Serum bilirubin is produced by the liver and secreted with bile. It can be measured in the blood. If there is an excess of bilirubin in the blood, it may indicate a blockage to bile flow, an inability of the liver to process bile, or an overproduction of bilirubin
2. Alkaline phosphatase is an enzyme that can be measured in the blood. This is a measure of the excretory functioning of the liver. Many tissues have alkaline phosphatase, but there are high amounts in the liver and bone. Alkaline phosphatase is elevated in obstruction of the biliary tree, metastatic disease and fatty infiltration
3. Serum aminotransferases are aspartate aminotransferase or AST and alanine aminotransferase or ALT. These enzymes, made in the liver, assess cellular integrity. ALT is especially elevated from abnormalities due to viruses or drugs. It is less elevated in alcoholic liver disease
4. Gamma glutamyl transferase or GGT is used to differentiate bone alkaline phosphatase, since its concomitant elevation indicates that the elevation in alkaline phosphatase comes from the liver

Question 166

Discuss how a patient is elevated for a coagulopathy

Answer 166

1. The ability of blood to clot depends on a number of different interactions, many of which can be affected by gastrointestinal tract diseases
2. Prothrombin becomes thrombin to promote clotting. If vitamin K is not adequately absorbed in the intestine, the level of prothrombin may be decreased. Diseases that disrupt liver function can lead to decreased levels
   
   • the conversion of prothrombin to thrombin involves a cascade of reactions involving factors, some of which are made in the liver
3. Prothrombin time or PT is used to assess the speed with which blood clots. Increased clotting times reflect liver disease, malnutrition, or certain genetic diseases
4. The activated partial thromboplastin time or APTT is another test to measure blood clotting
5. The International Normalized Ration or INR is derived by comparing the patient’s PT with the mean level of a large group for people

Question 167

Discuss some blood tests for viral hepatitis

Answer 167

1. Hepatitis can be caused by a number of viruses
2. Hepatitis B surface antigen or HBsAg can be detected in carriers, as well as in patients with acute or chronic infection with Hepatitis B
3. Hepatitis B core antibody or HBcAB is found in acute and post infectious cases. Immunoglobulin M would be needed to determine active infection; Immunoglobulin G denotes post infection
4. Hepatitis B e antigen or HBeAg indicates a significant infection, but the patient is no longer contagious
5. Hepatitis A antibody or HAVAB is detected in ongoing infections and in those recovered from infection
6. Hepatitis C is detected by finding anti-HCV in the patient. However in patients with an acute hepatitis C infection may not produce antibodies for a number of months
7. Hepatitis D only infects those with hepatitis B infection

Question 168

Discuss. The use of urinalysis in gastrointestinal diseases

Answer 168

1. Urine bilirubin measures the amount of direct bilirubin; elevations suggest liver or biliary disease
2. Urine urobilinogen when elevated, reflects the inability of liver cells to handle urobilinogen, which is produced from intestinal breakdown of bilirubin
3. Schilling test is a test to measure the ability of the small bowel to absorb vitamin B12. Radioisotopes are administered orally with and without intrinsic factor. B12 is also given intravenously. Assessing the various amounts of radioisotopes in a 24-hour urine can suggest the cause of vitamin B12 malabsorption

Question 169

Discuss some tests that can be done on feces

Answer 169

1. Fecal urobilinogen can be decreased in biliary obstruction, causing clay colored stools
2. Fecal occult blood indicates gastrointestinal bleeding. Three samples must be assessed. A small sample is placed on a hem occult card and treated with a reagent. If the sample becomes blue, it indicates blood. Certain foods and vitamins can lead to false positives
3. Fecal fat is assessed as a measure of malabsorption and excess fetal fat or steatorrhea. Stools should be collected over 72 hours, and the amount of fat in the stool is compared to the fat ingested during that time by the patient
4. Fecal chymotrypsin levels can indicate insufficiency or pancreatic exocrine function
5. Stools can be collected to assess for ova and parasites, white blood cells and organisms. The sample cam also be cultured

Question 170

Discuss ways to diagnose H. Pylori infection

Answer 170

1. Infection with H. Pylori is associated with peptic ulcer disease. Treatment of the organism may alleviate ulcer disease
2. Detection of H. Pylori disease can be done with blood tests, breath tests, stool tests and biopsy specimens
3. The urea breath tests are done by having the patient drink a urea solution with labeled carbon. H. Pylori breaks down the urea, the carbon is absorbed and then the carbon is eliminated through the lungs
4. The carbon-13 blood test measures antibodies to H. Pylori
5. H. Pylori stool antigen test or HpSA test detects the H. Pylori antigen in the stool

Question 171

Discuss the purpose of esophageal dilatation

Answer 171

1. Esophageal dilatation is performed to treat abnormalities that result in patients having difficulty eating. The procedure can be done on a daily basis, if needed. Those who cannot cooperate have had a recent major cardiac or pulmonary event, or have a coagulopathy should not undergo esophageal dilatation
2. Complications of dilatation may include perforation, bleeding, aspiration or infection. Perforation needs to be identified quickly. That may require x-rays looking for inappropriate collection of air or lung abnormalities. Surgery may be necessary

Question 172

Describe sheer-force dilators

Answer 172

1. Bougies are one kind of sheer-force dilator that can be used. These are made of rubber or silicone and are weighted with mercury or tungsten. These are called the Hurst or Maloney dilatators. The Maloney dilators are tapered; the Hurst dilators are rounded
   - these dilators are used to treat strictures, rings or webs, diffuse esophageal spasm and scleroderma
2. The other sheer-force dilator is the Savary-Gilliard or American dilators. These are made of polyvinyl chloride. The dilator is placed over a guidewire that was positioned by endoscopy
   - these kinds of dilatators are used to treat esophageal strictures or to place a stent

Question 173

Discuss the procedure of bougienage

Answer 173

1. The lubricated boogie is passed into the esophagus. When the narrowing is encountered, the physician carefully pushes the instrument forward
2. Each bougie must be carefully inspected to be sure it is in good condition
3. Cleaning the bougie requires use of an enzymatic cleaner and to fulfill disinfection instructions supplied by the manufacturer. The instrument is then rinsed, completely dried and stored in a horizontal position
4. Rubber bougies need to be removed quickly from cleaning solutions to prevent damage
5. Silicone bougies must be cleaned with mild soap and water

Question 174

Discuss some of the nursing duties during the esophageal dilatation

Answer 174

1. The nurse must ascertain that the patient has been NPO for at least six hours, that the medical history is accurate, that the patient understands the procedure and why it’s being done, remove dentures, establish basic vital signs and start an IV
2. The nurse must help the patient to maintain his/her position to reduce the risk of perforation. Use of a guidewire requires the nurse to inspect it and to hold the loose ends as the physician passes it
3. The nurse must keep the physician informed of vital signs, signs of complication and evidence of blood on the equipment or in any secretions
4. The nurse may need to apply suction to help the doctor or to provide comfort for the patient

Question 175

Discuss the procedure employing a hydrostatic balloon

Answer 175

1. Hydrostatic balloons can be used to dilate strictures in the esophagus, the pylorus, the duodenum, the rectum or the left colon. It can also be used for biliary tract strictures and to treat certain food impactions
2. Hydrostatic balloons are filled with either water or dilute radiopaque dye. The through-the-scope balloons go through the biopsy channel of the endoscope and inflate to a diameter of 4 to 25 millimeters. The over-the-guide wire balloons can be inflated to a diameter of 4 to 40 millimeters
3. The balloon must be checked for leaks before they are used
4. Once inserted to the appropriate location, the balloon can be inflated according to orders or to manufacturer’s instructions. The inflated balloon remains for a short period and is then deflated. This may be repeated, if the patient tolerates it.
5. When the balloon is removed it must be inspected for blood
6. After its use, the balloon is cleaned, disinfected and stored according to the manufacturer’s instructions

Question 176

Discuss the use of pneumatic balloons

Answer 176

1. Pneumatic balloons are used to stretch the LES. This is needed in patients with achalasia. This maneuver causes the circular muscle to tear, reducing the pressure. Pneumatic balloons may also be a second line treatment for esophageal rings that have not responded to bougienage
2. Many physicians prefer to have the patient observed over 24 hours. The patient is instructed to maintain a liquid diet the day before the procedure. Review of the procedure should include information that there may be pain, and there is medication available to help alleviate discomfort
3. The patient is under conscious sedation. The balloon is passed over a guidewire and then inflated when in place. Fluoroscopic evaluation should accompany the procedure. The esophagus must be cleared as needed. The physician should be notified if the dilator has blood when removed
4. Complications may include perforation, bleeding or aspiration. Some physicians do a follow-up contrast study to check for perforations or tears

Question 177

Discuss how electrocautery or electrocoagulation are used to control bleeding

Answer 177

1. Electrocautery or electrocoagulation employs an electrical current to a source of bleeding to coagulate tissue in order to stop bleeding. The instruments used are electrical surgical units. Care must be taken to ensure that all cords and connections are intact; the instrument should be tested prior to the procedure
2. For the upper gastrointestinal tract, a diagnostic endoscopy should locate the source and then therapy should be applied. There should be no blood in the stomach
3. For the colon, the bowel must be cleaned for proper visualization and to eliminate gases that might explode
4. The patient should be medically stable, and the nurse should educate and assure the patient. Also, the nurse must monitor the patient
5. Complications may include burns, bleeding, perforation and explosion

Question 178

Discuss monopolar electrocoagulation

Answer 178

1. Monopolar electrocoagulation applies current from the device to the local site. The patient has a grounding pad placed on the skin over a well vascularized, non-honey area. The subsequent heat generated leads to coagulation of the tissue. Soft, disposable pads provide the best contact. Patients need to be warned not to touch anything metal during the intervention.
2. It is important to avoid current leakage, which can lead to burns to the patient or burns to the operator. The nurse needs to attach the grounding pad appropriately, wear rubber gloves, avoid touching the patient during intervention, and be certain the patient does not touch metal.

Question 179

Compare bipolar electrosurgery and bipolar electrocoagulation

Answer 179

1. Bipolar electrosurgery requires greater expertise, but provides therapy as effectively as monopolar electrosurgery with less mucosal damage
2. Bipolar electrocoagulation does not use a grounding pad. Instead, it uses a bipolar probe, which handles the current. Water can be issued from the scope to clear the targeted area
3. Bipolar electrocoagulation offers some advantages over monopolar electrocoagulation. There is more control over the penetration depth so that perforations are less likely. The effect of bipolar electrocoagulation has less effect on surrounding tissue since it does not travel as far. This form of therapy can also provide the advantage of tamponading a vessel prior to coagulation.
4. Complications include perforation, bleeding and ulcerations

Question 180

Discuss laser therapy

Answer 180

1. Laser therapy can be used to treat gastrointestinal bleeding or to treat obstructing or abnormal lesions
2. Usually laser using Neodymium (Yitrium-Aluminum-Garnet or YAG Lasers) are operated by endoscopists, although some use Argon lasers. The laser transmits light energy to the targeted area by being passed through an endoscope. To avoid damaging the endoscope, appropriate scopes should be employed and treatments should be delivered when the laser is away from the scope.
3. Photocoagulation results from heat at 60 C and results in tissue coagulation. Photovaporization occurs at 100 C and is used to destroy or cut tissue.
4. After testing the laser, the preferred two-channel endoscope is inserted into the patient. The double channel allows for removal of generated gases. Everyone needs protective eye gear and a laser mask. Appropriate warning signs need to be in place to prevent inadvertent exposure
5. Complications include bleeding, perforation, ulceration, fistula formation or stricture formation

Question 181

Discuss how laser therapy is used in the treatment of gastrointestinal tumors

Answer 181

1. Laser therapy for gastrointestinal tumors focuses on controlling bleeding and obstructive symptoms, although curative therapy can sometimes be accomplished. The laser is passed through the endoscope, and it begins therapy on the target tissue closest to the lumen. The following treatments are administered in circles around the initial target area until, but not including, the wall of the gastrointestinal tract. Many operators prefer to use photocoagulation rather than vaporization because less smoke is generated
2. This form of therapy should be reserved for those who have no alternative for achieving a cure. Esophageal tumors may require several treatments to achieve results. Rectal tumors can often be done on an outpatient basis. If the tumor encroaches on the anus, appropriate medication needs to be administered because this may cause pain during treatment

Question 182

Discuss photodynamic therapy

Answer 182

1. Photodynamic therapy or PDT uses a red-light laser to treat abnormalities, such as dysplasia, Barrett’s esophagus or superficial adenocarcinomas. The patient is given a medication beforehand that concentrates in the abnormal tissue. The medication makes the tissue sensitive to light. The red-light laser destroys the targeted tissues. Patients must avoid sunlight for a litter more than a month
2. Although there are some side effects, such as nausea, swallowing difficulties or pain, this treatment offers the advantage of not having to use heat in the treatment intervention

Question 183

Describe sclerotherapy

Answer 183

1. Sclerotherapy involves injecting a sclerosing agent into varices to stop bleeding. It can also be used to control bleeding from hemorrhoids. This function is to destroy the vessel causing the bleeding. Commonly, one of three sclerosing materials used: Scleromate, Sotradecol, or Ethamolin. The latter is the least likely to cause ulcers. Some patients can manifest an allergic reaction to these agents
2. If the patient is actively bleeding, visualization is difficult. Bleeding can be tempered by using vasopressin or balloon tamponade. For those bleeding, the initial treatment should be administered just above the point of origin and then to either side of the initial injection site. It is also important to treat the area below the bleeding varix
3. Complications may include perforation, ulceration or stricture formation

Question 184

Explain the use of esophageal-gastric tamponade

Answer 184

1. Esophageal-gastric tamponade allows the operator to tamponade bleeding areas by applying pressure to those areas with tubes. This procedure is usually reserved for hemorrhaging that has not responded to other therapies
2. After determining that the equipment is in good working order, it is inserted, and then its placement is checked by x-ray. The gastric balloon is slowly inflated once the stomach has been cleared. This is pulled back to exert pressure on the lumen to provide tamponade. If this does not stop the bleeding, the esophageal balloon should be used. The gastric and esophageal balloons can be inflated together if the source of the bleed is esophageal. The tamponading can be discontinued after 24 hours if the bleeding has stopped.
3. Compilations may include rupture, aspiration or tissue necrosis

Question 185

Describe how the nasogastric tube is placed

Answer 185

1. There are many nasogastric tubes available for use. The function of the tube must be considered in terms of how it would be used. Suction and feedings may require a larger bore tube
2. Those tubes most commonly used are the Levin tube, the Salem sump tube, the extended use nasogastric feeding tube, the Moss tube, and the Compat tube
3. Determining that the patient can tolerate the tube is important, including prior surgeries or fractures. A lubricated tube is inserted in one of the nostrils, having the patient put chin to chest upon entering the area above the trachea. Care should be taken to avoid cannulating the respiratory system. Confirming proper placement may be ascertained by passing air through the tube and listening for appropriate sounds via the stethoscope.
4. The tube should be anchored for stability

Question 186

Describe the various nasogastric tubes

Answer 186

1. The Levin tube works like a vacuum, sticking to the stomach mucosal surface. Therefore, constant suction should not be applied
2. The Salem sump tube has two limes, one for suction and drainage and one for venting. The venting channel does not allow a vacuum to form
3. The extended-use nasogastric feeding tube can remain in place for about a month
4. The Moss tube has two lumens with ports for balloons, duodenal feedings and aspiration
5. The Compat tube has a port for decompressions and drainage. This port can also be used to give medications

Question 187

Describe the purpose of a PEG tube and the procedure for its placement

Answer 187

Percutaneous endoscopic gastrostomy (PEG), used for tube feedings, involves intubation of the esophagus with the endoscope and insertion of a sheathed needle with a guidewire through the abdomen and stomach wall so that a catheter can be fed down the esophagus, snared, and pulled out through the opening where the needle was inserted and secured. The PEG tube should not be secure to the abdomen until the PEG is fully healed, which usually takes 2 to 4 weeks, because tension caused by taping the tube against the abdomen may cause the tract to change shape and direction. The tract should be strait to facilitate insertion and removal of catheters. Once the tract has healed, the original PEG tube can generally be replaced with a balloon gastrostomy tube. External stabilizing devices can be applied to the skin to hold the tube in place but should be placed 1 to 2 cm above the skin surface to prevent excessive tension that may result in buried bumper syndrome (BBS) in which the internal fixation device becomes lodged in the mucosal lining of the gastric wall, resulting in ulceration

Question 188

Describe the Transjugular intrahepatic portosystemic shunt

Answer 188

1. Transjugular intrahepatic portosystemic or TIPS shunts can alleviate portal hypertension without surgery. This is a new procedure, and long-term outcomes have, therefore, not been assessed
2. The right hepatic vein is accessed via a wire from the right internal jugular vein. A sheath is then passed into the portal vein and an angioplasty balloon is inflated. A stent is placed from the hepatic vein to the portal vein. This allows shunting of the blood to the inferior vena cava
3. Complications may include perforations, bleeding, infection and subsequent blockage of the stent

Question 189

Describe the methods used in polypectomy

Answer 189

1. Polyps can be removed by a polypectomy snare or by hot biopsy forceps. Different polyps require different equipment and techniques. Some polyps need to be ensnared, some need to be removed in pieces, others are efficiently removed with just a hot biopsy forceps. For multiple polyps, the operator may have to make several passes
2. Once the polyp is removed, it is examined for the presence of cancer. The operator may re-insert the scope to assess the excised area
3. Complications may include bleeding, perforation, explosion from gases, or burns from the equipment
4. Sometimes bleeding can be managed with immediate treatment with the available equipment. The operator may ensnare the area, holding it until bleeding is stopped. Also, electrocoagulation, treatment with a heater probe, or injection therapy may be used

Question 190

Discuss some non-invasive treatments for gallstones

Answer 190

1. Extracorporeal shock-wave lithotripsy or ESWL uses shock waves to break up stones instead of undergoing a cholecystectomy. The results are better in those with less than 3 stones, adequate gallbladder function and thin habitus. This method is often used with dissolution of gallstones
2. There have been occurrences of obstruction requiring subsequent ERCP
3. Another method to deal with stones in the use of the pulsed-dye laser. The laser is fired at a point in contact with the quartz wire, fragmenting the stone
4. This method is more rapid and can treat a larger number of stones than ESWL

Question 191

Discuss surgical interventions for esophageal disorders

Answer 191

1. GERD that does not respond to medical management may be treated by surgery. The most common procedure, a Nissen fundoplication, involved wrapping the stomach around the lower esophagus to act as a sphincter. This can be done through laparotomy or laparoscopy. There are also some investigational procedures that are promising.
2. Achalasia may require surgical intervention. Heller’s myotomy is the usual surgical procedure. The esophagus is approached from within and cuts are made to the lower musculature of the esophagus. This causes relaxation of the LES. Since reflux symptoms are a common complication of this procedure, another procedure to treat the development of those symptoms is performed, as well
3. Surgery for esophageal cancer in the distal 2/3 of the esophagus can be performed for localized disease. Through an abdominal incision, the diseased area is removed. The esophagus is then reattached to the stomach. Enteral feeding through a gastrostomy tube can be utilized during the acute recovery period

Question 192

Discuss surgical procedures for gastric disorders

Answer 192

1. Hiatal hernias may be repaired surgically by reducing the hernia and tacking the anatomy into place
2. Obesity can be addressed through surgical intervention, either vertical banded gastroplasty or Roux-en Y gastric bypass. In the banded procedure, staples stretch from the fundus to the upper part of the lesser curvature. This cuts off access of food to rest of the stomach. With the Roux-en Y, the fundus-lesser curvature pouch is created, but also the jejunum is fixed to the pouch. The duodenum is then fixed to the jejunum
3. Peptic ulcer disease can be treated surgically with Billroth I, Billroth II, vagotomy or a combination of these procedures
4. A perforated ulcer can be treated with suturing acutely, followed at a later time with one of the procedures mentioned for ulcer disease therapy
5. Hypertrophic pyloric stenosis can be treated with pyloromyotomy, cutting the muscles around the pylorus
6. Gastric cancer can be removed by surgery. If the entire stomach must be removed, the esophagus is attached to the jejunum

Question 193

Discuss surgical procedures for pancreatic disorders

Answer 193

1. Pancreatic cancer can be treated with surgery. The intervention is called Whipple’s procedure and it technically a pancreaticoduodenectomy. The surgery removes half the stomach, the duodenum, the proximal jejunum, the gallbladder, the distal biliary tree and the head, neck and uncinate process of the pancreas. A modified form of this procedure does not remove the stomach and upper part of the duodenum. With added radiation therapy and chemotherapy, outcomes have improved in recent years
2. For intractable or life-threatening pancreatitis, pancreaticoduodenectomy may be attempted

Question 194

Discuss surgical procedures for disorders of the colon

Answer 194

1. Hirschsprung’s disease is treated by removing the affected part of the bowel
2. Inflammatory bowel disease may require surgery for control of symptoms or complications. Removal of the colon is done with connection of the ileum to the rectum, if the rectum is clear. If not, an ileostomy will need to be accommodated
3. Colon cancer can be treated by surgery. Removal of the affected bowel can be performed
4. Colon perforation can be treated by closure and rinsing of the abdominal cavity. Part of the colon may need to be removed in some cases

Question 195

Define: gastrointestinal manometry, respiration inversion point, scleroderma, Bernstein test, and anorectal manometry

Answer 195

1. Gastrointestinal manometry is used to assess pressures and motility in the gastrointestinal tract
2. Respiration inversion point is the movement of the manometric catheter from the abdominal cavity into the thoracic cavity
3. Scleroderma is a connective tissue disease that leads to the loss of esophageal motility because of absent muscle contraction
4. Bernstein test is a provocative test using exogenous acid exposure to reproduce chest pain
5. Anorectal manometry assesses the response of the internal and external sphincters to the stimulus of bowel distention

Question 196

Define: Systemic Amyloidosis, hot biopsy forceps, rectal culture, Carey capsule, Crosby capsule, frozen section biopsy, and brush cytology

Answer 196

1. Systemic Amyloidosis is the abnormal condition of the buildup of amyloid in the intestinal wall
2. Hot biopsy forceps are for electrocoagulating tissue for those at increased risk of bleeding
3. Rectal culture is accomplished by swabbing the rectal area looking for infectious disease
4. Carey capsule is equipment that allows for small bowel biopsy
5. Crosby capsule is equipment that allows for small bowel biopsy
6. Frozen section is a biopsy the is immediately mounted and examined for quick results
7. Brush cytology involves passing a tiny brush through the biopsy channel

Question 197

Define: Barium swallow, upper gastrointestinal series, enteroclysis, barium enema, arteriography, computed tomography, and biliary drainage studies

Answer 197

1. Barium swallow is a study in which a patient swallows the radiopaque contrast so that the esophagus can be evaluated
2. Upper gastrointestinal series or UGI with small bowel follow through allows the evaluation of the gastrointestinal tract through the small bowel by using radiopaque barium
3. Enteroclysis allows for injection Barium through a tube to evaluate the small bowel
4. Barium enema used radiopaque Barium to assess the colon
5. Arteriography or angiography is a test in which arteries are injected with contrast medium to assess bleeding, trauma or vascular abnormalities
6. Computed tomography or CT is an imaging study that computes the different densities of tissues to make an image
7. Biliary drainage studies require that a tube be passed into the duodenum and then the gallbladder is stimulated to contract. Secretions are collected and examined

Question 198

Define: Hemoglobin, hematocrit, bleeding time, platelets serum d-xylose test, glucose tolerance test, serum cholesterol, carcinoembryonic antigen, and breath tests

Answer 198

1. Hemoglobin reflects the pigment responsible for carrying oxygen in the red blood cell
2. Hematocrit defines the percent volume of red blood cells to the whole blood
3. Bleeding time is measure of platelet function. The time it takes a patient to clot after a cut can be timed
4. Platelets, manufactured in the bone marrow, are blood cells that help in clotting blood. If they are low, the patient will have a tendency to bleed
5. Serum d-xylose test assesses the ability of the small intestine, particularly the upper small bowel, to absorb necessary substances
6. Glucose tolerance test assesses a patient’s ability to respond to a glucose challenge. Abnormal responses suggest diabetes
7. Serum cholesterol is measured for a number of reasons. Elevated levels are associated with increased cardiac disease and may be caused by certain diseases, including gastrointestinal diseases
8. Carcinoembryonic antigen levels are elevated with certain forms of cancer or inflammatory diseases
9. Breath tests require the measurement of exhaled gases after the ingestion of a labeled substance

Question 199

Define: Bougienage, Maloney dilator, Hurst dilator, Savary-Gillard dilators, Rigiflex dilators, and French units

Answer 199

1. Bougienage is the procedure to dilate the esophagus by using a weighted bougie to push through an esophageal narrowing
2. Maloney dilator is a bougie with a tapered end used in esophageal dilatation
3. Hurst dilator is a bougie filled with mercury for dilating the esophagus
4. Savory-Gilliard dilators are polyvinyl dilators that have a channel for a guidewire
5. Rigiflex dilators are pneumatic balloons use to dilate the lower esophageal sphincter
6. French units are the measurement used to designate the size of an esophageal dilator. It reflects the circumference of the dilator

Question 200

Define: heater probes, bipolar probe, monopolar electrocoagulation, electro surgical units, photocoagulation, photovaporiztion, Ethamolin, Sengstaken-Blakemore tube, Linton tube, and Minnesota tube

Answer 200

1. Heater probes are hollow aluminum cylinders with a heating coil to cause tissue coagulation
2. Bipolar probe is an electrode used in electrocoagulation in which the probe delivers the current and completes the circuit
3. Monopolar electrocoagulation uses a single pole to produce coagulating current
4. Electrosurgical units are instruments used to deliver electrocoagulation therapy
5. Photocoagulation occurs at 60 C and causes tissue coagulation
6. Photovaporization occurs at 100 C and cuts or destroys tissue
7. Ethamolin is Ethanolamine oleate, a sclerosing agent
8. The Sengstaken-Blakemore tube is used in tamponade with a gastric and esophageal balloon
9. The Linton tube is used in tamponade but has no esophageal balloon
10. The Minnesota tube is used in tamponade. It has a gastric and esophageal balloon and also lumens to allow for both gastric and esophageal suction

Question 201

Define: Billroth I, Billroth IIm Roux-en Y, esophageal atresia, and Nissen fundoplication

Answer 201

1. Billroth I is a surgical procedure for peptic ulcer disease in which the antrum of the stomach is removed with attachment of the duodenum to the remainder of the stomach
2. Billroth II is a surgical procedure for peptic ulcer disease in which the upper duodenum and lower stomach are removed with the jejunum being attached to the remainder of the stomach
3. Roux-en Y is a surgical procedure that creates a pouch in the proximal area of the stomach. The jejunum is attached to the pouch, and the duodenum is attached to the jejunum
4. Esophageal atresia results at birth with the esophagus ending blindly, unattached to the stomach
5. Nissen fundoplication is used to strengthen the LES by wrapping the stomach around the lower esophagus and suturing it in place

Question 202

Discuss the equipment required in the gastroenterology procedure room for the case of emergency resuscitation

Answer 202

1. Resuscitation equipment should be readily available in the gastroenterology procedure room so that a patient in distress can be quickly resuscitated. This equipment is in addition to monitoring equipment used during the procedure: pulse oximeters, ECG, automated sphygmomanometers, and capnography. Equipment required for emergency resuscitation includes:
   - intravenous equipment - includes various IV and intraosseous bone marrow needles, syringes, tubing and catheters
   - airway management equipment - suction equipment, catheters, airways, LMAA, laryngoscopes, Endotracheal tubes, stylets, oxygen source, positive pressure equipment
   - reversal agents - naloxone (Narcan) and Romazicon (Flumazenil)
   - emergency medications: include epinephrine, ephedrine, atropine, amiodarone, diphenhydramine, steroids, diazepam, midazolam, and lidocaine
   - defibrillator
2. All equipment should be routinely checked to make sure it is operating condition. Medications should be rotated and expiration dates checked to ensure they are not outdated

Question 203

Discuss measures to investigate a gastrointestinal bleeding source

Answer 203

1. Gastrointestinal bleeding can be minor, but it can also be life-threatening. The nurse helps to assess the patient, ascertaining vital signs, oxygenation and comfort. Appropriate measures must be instituted to offer support to the patient
2. The first course of action is medical stabilization. This may require central venous access, resuscitative efforts, or other invasive maneuvers
3. Once the patient is stabilized, searching for the source of bleeding becomes important so that corrective measures can be taken
4. Investigating for an upper gastrointestinal site may require placing a nasogastric tube, looking for blood. An endoscopy may be performed, depending on the medical stability of the patient
5. For lower gastrointestinal bleeds , an upper gastrointestinal source needs to be ruled out. A scan to follow tagged red blood cells may point to a source. A colonoscopy may be performed for visualization, if the patient can tolerate the procedure. Surgery is always a possibility in gastrointestinal bleeding

Question 204

Discuss perforation of the gastrointestinal tract

Answer 204

1. Perforation results in a hole in the gastrointestinal wall. This may be the result of trauma or underlying pathology. Although uncommon, endoscopic procedures can lead to perforations. Those at risk often have a predisposing factor, such as strictures or malignancies
2. Perforations in the upper gastrointestinal tract commonly present with pain. The location of the pain is related to the area of perforation. Gastric perforations are less common than esophageal perforations. Many perforations can be managed conservatively, although a surgical consult is needed. Patients who demonstrate complications, such as peritonitis, need immediate intervention
3. Perforations of the lower gastrointestinal tract are often asymptomatic. However, the symptoms can rapidly progress. Usually, these need surgical intervention

Question 205

Discuss hopovolemic shock

Answer 205

1. Shock is the state of a patient who cannot maintain his/her cardiovascular status. This may be due to blood or fluid loss or to factors that undermine the control of the circulatory system, such as sepsis. Hypovolemic shock results from a lack of body fluids to support the circulatory system. The body alters its circulatory priorities to favor central organs, such as the heart and the brain. This is done at the expense of other organ systems, such as the kidney. Patients are tachycardia and anxious. As the shock progresses, patients become hypotensive
2. Patients should be given appropriate volume support with fluids or other volume expanders. The feet should be elevated. Drugs to maintain perfusion may be used. Treating the underlying cause must be aggressively attempted, once the patient is stabilized

Question 206

Discuss septic shock

Answer 206

1. Septic shock can accompany bacteremia, leading to cardiovascular compromise. Any source of infection can lead to septic shock, including gastrointestinal infections. The patient may initially present with fever, chills, and borderline blood pressure. If untreated, this can progress to cardiovascular collapse, not unlike advanced hypovolemic shock
2. Treatment requires aggressive support of the patient, with fluids and blood pressure source. Treating for infection should begin immediately. Investigation of the source of infections should be addressed to implement appropriate corrective action
3. Some gastrointestinal procedures are associated with a rate of infections complications, such as ERCP or dilations. Most agree that antibiotics should be reserved for high risk patients, such as patients with a history of endocarditis

Question 207

Discuss adverse drug reactions

Answer 207

1. Every medication has potential side effects, or unwanted actions on the individual. Being aware of these side effects can enable the clinician to anticipate adverse events. Actions to deal with adverse events can then be taken, as needed. In addition, cautious use and administration of any medication should always be pursued
2. Many individuals have allergies to medications, and some of those are unaware of their allergies. The clinician should always determine an allergic history, but should also be prepared for an unexpected allergic reaction. In addition, some individuals are allergic to latex, a ubiquitous substance in medical settings
3. There should always be a full array of emergency equipment available in the event that a patient needs to be resuscitated. For anaphylaxis, immediate treatment with epinephrine can minimize the adverse effects. Other supportive measures need to be implemented, as well

Question 208

Discuss appropriate resuscitative measures in the case that the patient has a negative response to anesthesia

Answer 208

Negative responses to anesthesia vary according to the type of anesthetic agent administered, but can include:

1. Respiratory depression: the dosage may need to be decreased. With opioid depression, naloxone may be administered: and with benzodiazepine depression, Romaxicon (Flumazenil). Supplementary oxygen and positive pressure ventilation may be required
2. Airway obstruction: airway may require suctioning, jaw thrust, and administration of oxygen with a BVM to clear obstruction. Succinylcholine may be needed for laryngospasm, epinephrine for laryngeal edema, and albuterol and epinephrine for bronchospansm.
3. Hypotension/bradycardia: treatment may include atropine, ephedrine, and/or phenylephrine
4. Hypertension: Treatment may include nitroglycerin and labetalol
5. Malignant hyperthermia: the anesthetic agent should be immediately discontinued although surgery may continue with different agents. The patient should be hyperventilated with 100% oxygen and Dantrolene 2.5mg/kg and 1.2mEq/kg of sodium bicarbonate administered IV through a central line or large bore IV. Ice packs are applied to groin, axillary, neck, wrists and ankle, and iced lavage of stomach and rectum as needed to reduce temperature. Other treatments may include mannitol or furosemide, procainamide, calcium, and insulin

Question 209

Discuss cardiac arrest in the gastrointestinal suite

Answer 209

1. Cardiovascular events are a potential side effects for patients undergoing procedures. Patients may be at risk from the actual procedure, increased anxiety or reactions to medications. For those at risk, EKG monitoring should be provided throughout the study
2. Emergency equipment should be available, and should be checked daily to assess function and completeness
3. If cardiac arrest occurs, CPR should be instituted. IV fluids and medications should be administered, and the airway should be secured. Outcomes are much more favorable for those who receive early action. Documentation of all events and actions is imperative

Question 210

Discuss appropriate resuscitative measures in the case of cardiac arrest

Answer 210

Cardiopulmonary resuscitation for cardiac arrest:

1. Immediate defibrillation (one shock) for VT/VF (shockable rhythms) according to protocol with manual defibrillator (preferred over AED) followed by CPR, beginning with compression (30:2 compressions to ventilation at the rate of 100-120 per minute at at least 2 inches deep; 2-finger compression, 1/3 chest depth for infants and children) for two minutes/5 cycles and repeat defibrillation. Non-shockable rhythms (PEA/asystole) do not respond to defibrillation
2. Obtain IV/IO access; begin PETCO2 if available
3. Administer epinephrine 1mg every 3 to 5 minutes
4. Repeat cycles of 2 minutes CPR and defibrillation
5. If defibrillator is not readily available, CPR may begin first. Note if BVM is used, the break in compressions should not exceed 10 seconds. If an advanced airway/intubation is in place, ventilation should be at the rate of 8 to 10 per minutes, maintaining oxygen saturation >or= to 94% but <100% with ventilation between compressions
6. Adrenaline (IV 1mg) and vasopressin (40 units) may be repeatedly administered with PEA, asystole, or VF and when two shocks have been unsuccessful
7. ETCO2 value should be 10-20mmHG if chest compressions are adequate, increasing to 35 to 45mmHg with return of spontaneous circulation (ROSC)

Question 211

Discuss respiratory depression in the gastroenterology suite

Answer 211

1. Respiratory depression can result from some of the medications used during gastrointestinal procedures. Patients will demonstrate a decreased respiratory rate and a drop in oxygen saturation
2. Clinicians need to be cautious with the administration of medications. Certainly, titration rates should be slow, along with using the lowest effective dose. Modification may be needed for the elderly or for those with underlying medical conditions
3. Increasing the oxygen provided to the patient is necessary and sometimes sufficient. Drugs that depress the respiratory system may have to be reversed with appropriate antagonists
4. With respiratory arrest, emergency measures should be instituted immediately, providing support for the airway and the cardiovascular system. CPR should be undertaken and appropriate medications should be administered

Question 212

Define: perforation, hematochezia, melena, hematemesis, Boerhaave’s syndrome, bacteremia, anaphylaxis, Cheyne-Stokes respirations, vasovagal syncope and aspiration

Answer 212

1. Perforation is an opening through the wall of the gastrointestinal tract
2. Hematochezia occurs when the individual has bloody stools.
3. Melena occurs when the individual produces odiferous, tarry stools
4. Hematemesis is vomiting blood
5. Boerhaave’s syndrome results in perforation that occurs spontaneously, usually associated with vomiting
6. Bacteremia is the presence of bacterial organisms in the blood
7. Anaphylaxis is a severe allergic reaction that results in cardiovascular collapse and possibly death
8. Cheyne-Stokes respirations are periods of increased respirations interspersed with periods of decreased respirations
9. Vasovagal syncope is a transient loss of consciousness due to a neurologic and cardiovascular response to fear or pain
10. Aspiration is the inappropriate introduction of substances to the respiratory system

Question 213

Outline the use and dosages for the following emergency medications: Romazicon (Flumazenil) and atropine

Answer 213

Emergency medications include:

1. Romazicon (Flumazenil): used to reverse the sedative effects of benzodiazepines (often used as sedation for medical procedures and surgery), such as alprazolam (Xanax), midazolam (Versed), clorazepate dipotassium (Tranxene) and diazepam (Valium). Romazicon does not, however, reverse respiratory depression. Romazicon is administer IV with a beginning dose of 0.2mg over 30 seconds with repeat doses at one-minute intervals as needed. The second dose is 0.3mg and the third and subsequent doses are 0.5mg
2. Atropine: used in emergency situations to treat asystole, ventricular fibrillation, and pulseless electrical activity, atropine increases heart rate. The dosage is usually 0.5-1mg IV every 3-5 minutes to a maximum of 3mg. Atropine is also an antidote for muscarinic poisoning caused by overdose of medications, such as Bethanechol and cholinesterase inhibitors

Question 214

Outline the use and dosages for the following emergency medications: Naloxone (Narcan) and epinephrine

Answer 214

Emergency medications include:

1. Naloxone(Narcan): Opioid antagonist rapidly reverses the effects of opioid overdose, such as from heroin or prescription opiates/opioids. The injectable form (IV,SQ,or IM) is more commonly used by medical personnel and is generally more effective than the nasal spray. Initial dosage is 0.4mg for adults/10mcg//kg for children with dosages repeat at 2-to 3 minute intervals as needed. For postoperative opioid effects, initial dosage is 0.1 to 0.2 mg IV repeated at 2 to 3 minute intervals as needed
2. Epinephrine: used to treat anaphylaxis and life-threatening allergic reactions. Administered SQ,IM,IV or intracardiac, epinephrine is a bronchodilator and vasoconstrictor and restores cardiac function in those experiencing asystole. The usual SQ/IM dosage is 0.1% (1:1000) and IV/intracardiac dosage is 0.01% (1:10,000)

Question 215

Outline the ASA sedation guidelines

Answer 215

The ASA sedation guidelines (2018) are intended for moderate (conscious) sedation used for procedures. Steps include:

1. Pre-procedure evaluation: includes review of health records, physical examination and laboratory testing as indicated a few days or weeks prior to the procedure and re-evaluating the patient again before the procedure
2. Patient preparation: consult with specialist if indicated, ensure patient has informed consent and has been compliant with pre-procedure fasting
3. Patient monitoring: LOC (every 5 minutes), oxygenation/ventilation (capnography, pulse oximetry), and hemodynamic with designated person responsible for monitoring and recording
4. Supplemental oxygen: Use unless contraindicated by condition
5. Emergency interventions: Resuscitative equipment and reversal agents for opioids (naloxone) and benzodiazepines (Romazicon) myst be present with person trained in assessment and use available
6. Sedatives: Combinations of drugs as appropriate may be used (benzodiazepines and dexmedetomidine) and analgesics (opioids)
7. Sedative (propofol, ketamine, etomidate) and analgesics (local anesthetic, NSAIDs and opioids) intended for general anesthesia: Care must be consistent with that of general anesthesia and IV medications administered incrementally
8. Recovery care: Monitor oxygenation, ventilation, and circulation every 5 to 15 minutes

Question 216

Discuss guidelines regarding assessing the patient’s airway status before, during and after anesthesia administration

Answer 216

According to ASA guidelines, the patient’s airway status must be continually evaluated and monitored:

1. Before anesthesia: the patient’s records should be reviewed for evidence of airway compromise, such as a history of sleep apnea, COPD, asthma, or bronchospasm. The airway should be evaluated as part of the physical examination. Specialists should be consulted if indicated to provide guidance regarding sedation and maintenance of a patient airway
2. During anesthesia: the patient should receive supplemental oxygen unless specifically contraindicated by condition. The patient’s capnography and pulse oximetry should be continuously monitored and the patient’s general condition monitored for signs of respiratory distress/depression or hypoxemia
3. After anesthesia: The patient’s oxygenation must be continually monitored until the patient is alert and responsive and no longer at risk for respiratory compromise. Ventilation and circulation should be assessed at 5-to-15 minute intervals or more often if indicated by condition

Question 217

Discuss how nutrients are prepared for used by the body

Answer 217

The six basic nutrients include carbohydrates, lipids, proteins, vitamins, minerals, and water

1. Carbohydrates are immediately acted upon by the salivary enzyme, ptyalin, which produces disaccharides. These are further broken down in the small intestine into monosaccharides. These are absorbed and become part of the glucose metabolism that fuels the energy of each cell. Glucose is stored in the liver as glycogen
2. Lipids are hydrolyzed and once they enter the small intestine they are converted to triglycerides. In various forms, these are emulsified and absorbed in the small bowel
3. Proteins contain amino acids, some of which are necessary for continued health. After they are hydrolyzed in the stomach, they are further broken down for absorption by pancreatic enzymes. They are then absorbed
4. Vitamins are necessary for the health of the body. They include those that are fat soluble: Vitamins A,D,E,K. The balance of vitamins is water soluble
5. Minerals include substances such as calcium and phosphorus
6. Water is essential for cellular health, transport of nutrients and maintenance of body temperature

Question 218

Discuss various dietary limitations

Answer 218

1. Dietary fiber is important to maintain stool bulk and prevent constipation. Fiber can be provided through whole grains, fruits, vegetables or bran
2. For those suffering from diarrhea, a low fiber diet may be recommended
3. Those with celiac disease need to avoid gluten-containing foods such as wheat, rye, oats and barley. This is a difficult commitment, but patients should be encouraged because of the consequences, such as diarrhea and failure to thrive
4. Avoidance of lactose is needed for those who are lactose intolerant. This requires the avoidance of lactose-containing substances, such as milk. There are mild substitutes, as well as pills to that contain the missing enzyme, lactase
5. Low protein diets are required for those with severe liver or renal disease. Supplements may be added to prevent negative nitrogen balance
6. Low fat diets are often required to control gastrointestinal diseases that are accompanied by diarrhea or steatorrhea
7. Low sodium diets are often needed for patients with liver, renal or cardiac diseases

Question 219

Discuss the need for enteral feedings

Answer 219

1. Enteral nutrition is provided for those who cannot adequately consume foods. This is useful for those who have a functioning gastrointestinal tract. It provides advantages of total Parenteral nutrition because it is cheaper, is less invasive and is more tolerated
2. This form of nutrition is done through tubes accessing the gastrointestinal tract via the nose, the mouth or percutaneously
3. For long term access, a tube may be inserted surgically to the small bowel
4. The rate of feeding should be gradual, and then the concentration is gradually increased
5. This form of providing nutrition is less expensive and poses less risk than Parenteral nutrition

Question 220

Discuss some of the common problems with enteral feedings

Answer 220

1. Aspiration is the most common complication in these patients. Other complications include vomiting, diarrhea, constipation, local necrosis from tube placement, and electrolyte imbalances
2. The nurse must monitor the patient carefully, as well as careful assessment of the tube placement with intermittent feedings
3. Patient education is important for appropriate administration and care of the access channel. Patients should be encouraged to exercises and to participate in normal activities
4. Patients should also be reminded that a more normal mode of feeding will be started as soon as possible

Question 221

Discuss the need for total Parenteral nutrition or TPN

Answer 221

1. Total Parenteral nutrition provides for those who are unable to maintain their own nutritional balance independently. For this form of nutrition, an appropriate in dwelling catheter should be placed. Peripheral nutrition can be offered for some individuals, such as those who need short term support
2. Total Parenteral nutrition or TPN contains the essential nutrients that are obtained from a normal diet. The physician orders this on a daily basis. It requires careful calculation to meet the needs of the patient. Many hospitals have a dedicated team that addresses the needs of these patients
3. Complications may include sepsis, complications from central line placement, air embolism or thrombophlebitis

Question 222

Define: positive nitrogen balance, negative nitrogen balance, enteral nutrition, Percutaneous endoscopic gastrostomy, Percutaneous endoscopic jejunostomy, total Parenteral nutrition, minerals and nutrients

Answer 222

1. Positive nitrogen balance results when protein synthesis exceeds protein degradation
2. Negative nitrogen balance results when protein degradation exceeds protein intake
3. Enteral nutrition is provided for those who cannot eat but who have functioning bowels
4. Percutaneous endoscopic gastrostomy requires insertion of a gastrostomy feeding tube via the endoscope
5. Percutaneous endoscopic jejunostomy requires insertion of a jejunostomy feeding tube via endoscopy
6. Total Parenteral nutrition or TPN is nutritional supplementation for the patient with gastrointestinal dysfunction
7. Amino acids are combined to form proteins
8. Minerals are nutrients that are inorganic
9. Vitamins are nutrients that are organic

Question 223

Discuss the following interventions for pain management: ambulation, medication, positioning

Answer 223

Interventions for pain management includes:

1. Ambulation: Helps to increase circulation, to reduce the risk of thromboembolism, and to promote autonomy. Patient should be encouraged to count steps and to regularly increase the count. A pedometer may be useful to help the patient monitor activity
2. Medication: The type of pain dictates the medical response. For example, gas pain may be relieved by antacids; heartburn associated with reflux, antacids; abdominal cramping associated with constipation, stool softeners and/or laxatives; abdominal cramping associated with diarrhea, antidiarrheals; and rectal pain associated with hemorrhoids/fissures/fistulas, topical lidocaine/steroid preparation. Patients may receive relief from discomfort with acetaminophen and/or NSAIDs. Opioids, which may cause constipation, are reserved for severe pain, such as post surgical
3. Positioning: Changing positions may help to alleviate discomfort, but the type of positioning must be individualized depending on the type of discomfort and what works for the patient. If a patient has abdominal pain, for example, the patient may have some relief from elevating the knees or lying on the side with knees drawn up. If the patient has rectal pain, avoiding direct pressure to the rectal area may help to relieve discomfort

Question 224

Outline the requirements of HIPAA, and how these are applied to the gastroenterology unit

Answer 224

1. Sensitive information is classified under HIPAA as protected health information (PHI), applies to all healthcare, including gastroenterology patients, and includes:
   - any information about an individual’s past,present or future health or condition (mental or physical)
   - provision of health care provided to the individual
   - any information related to payment for healthcare services that can be used to identify the person
   - identifying information: name, address, social security number, birthdate and any document or material that contains identifying information (such as laboratory records)
2. Personal information can be shared with a spouse, legal guardians, those with durable power of attorney for the patient, and those involved in care of the patient, such as physicians, without a specific release. HIPAA mandates privacy and security rules to ensure that health information and individual privacy is protected:
   - privacy rule: protected information includes any information included in the medical record (electronic or paper), conversations between the doctor and other healthcare providers, billing information, and any other form of health information
   - security rule: any electronic health information must be secure and protected against threats, hazards, or non-permitted disclosure

Question 225

Discuss the process of obtaining patient consent prior to gastroenterology procedures

Answer 225

Patients or their representatives must be asked directly for signed informed consent prior to gastroenterology procedures. Informed consent requires that the person be competent to give consent; has been apprised of risks, benefits, and alternatives; comprehends the information provided; and gives consent without coercion. Children <18, unless legally emancipated, lack the legal right to give consent for medical treatments except in those areas approved by law, such as for birth control, abortion, and HIV testing, and even these vary from one state to another, with some requiring parent notification. However, children must be included in discussions about treatment options in accordance to their age and level of understanding. While state laws vary in relation to informed consent, generally the provision of emergency treatment is permissible without informed consent if the patient is unable to consent. For example, an accident patient who is unconscious can be treated if next of kin is not available to give consent. Generally, dementia alone does not negate the need for informed consent although that may be provided by a legal representative

Question 226

Outline the key ethical principles to be aware of when providing patient care

Answer 226

Key ethical principles to be aware of in providing patient care include:

1. Autonomy is the ethical principle that the individual has the right to make decisions about his/her own care, based on informed consent and understanding of risks and benefits. Ensuring that a patient has provided informed consent supports autonomy
2. Beneficence is an ethical principle that involves performing actions that are for the purpose of benefitting another person
3. Nonmaleficence is an ethical principle that means healthcare workers should provide care in a manner that does not cause direct intentional harm to the patient (although sometimes an action or treatment may cause harm as a means to achieve good, such as chemotherapy)
4. Justice is the ethical principle that relates to the distribution of the limited resources of healthcare benefits to the members of society. Distribution should be fair with all having equal access
5. Veracity refers to honesty and truth telling in all interactions with patients, families and other healthcare providers

Question 227

Discuss advance directives as they relate to the gastroenterology unit

Answer 227

In accordance to Federal and state laws, gastroenterology patients have the right to self-determination in health care, including decisions about end of life care through advance directives such as living wills and the right to assign a surrogate person to make decisions through a durable power of attorney. Patients should routinely be questioned about an advanced directive as they may present at a healthcare organization without the document. Patients who have indicated they desire a do-not-resuscitate (DNR) order should not receive resuscitative treatments for terminal illness or conditions in which meaningful recovery cannot occur. Patients and families of those with terminal illness should be questioned as to whether the patients are Hospice patients. For those with DNR requests or those withdrawing life support, staff should provide the patient palliative rather than curative measures, such as pain control and/or oxygen, and emotional support to the patient and family. Religious traditions and beliefs about death should be treated with respect

Question 228

Outline the following potential complications: flare ups, drug reactions, drug interactions

Answer 228

Potential complications the gastroenterology patient may experience include:

1. Flare ups: a sudden exacerbation of symptoms occurs with some gastrointestinal disorders, such as Crohn’s disease. Flare-ups may be associated with patient’s stopping or skipping doses of their medications, taking NSAIDs, taking antibiotics, or smoking. Flare ups may also result from increased stress and certain foods (which may differ from one individual to another)
2. Drug reactions: The adverse effects of many OTC and prescription drugs include GI problems, such as nausea, vomiting, and diarrhea. Many drugs of abuse adversely affect the GI system as well. For example, cocaine may cause intestinal infarction and opioids may cause severe constipation
3. Drug interactions: these interactions alter the effects of one or more drugs on the body when multiple drugs are taken, with the risk of interactions increasing with the number of drugs. Many drugs interact with grapefruit, inhibiting the metabolism of the drugs. Antacids may decrease the absorption of some drugs, such as digoxin and phenytoin and increase absorption of others, such as pseudoephedrine. Sodium bicarbonate may decrease excretion of some drugs, such as amphetamines and aspirin

Question 229

Outline the following resources available to the gastroenterology patient: Palliative care, support group, financial and social assistance

Answer 229

Resources available to the gastroenterology patient include:

1. Palliative care: Supportive are provided to help the patient manage symptoms, such as pain and nausea, in order to improve the patient’s quality of life. Palliative care should be available at all levels of care and may be provided in the home as part of Home Health care and Hospice care
2. Support groups: Usually peer groups of those with similar problems, such as living with Crohn’s disease, but led by a professional who can provide education and guidance. Often available through local hospital or medical groups at no cost to participants
3. Financial assistance: Some organizations provide care with a sliding scale, but assistance may be available through Medicaid (for healthcare) or Social Services, for assistance with living expenses and housing. In some cases, faith-based organizations, such as the Salvation Army or Catholic charities, may provide some financial assistance
4. Social assistance: Volunteer agencies, such as Friendly Visitors, and some senior citizen groups may provide companionship and some assistance, such as help in filing taxes and with transportation

Question 230

Discuss the role of the gastroenterology nurse in the realm of medication administration

Answer 230

1. Gastroenterology nurses and minister medications, as well as educate patients about medications. Therefore, the nurse needs to understand and appreciate the different drugs used in the field of gastroenterology. This includes appropriate dosing, rout of administration, side effects and drug interactions
2. The nurse needs to consider the patient’s needs and limitations, taking into account the age of the patient, medical history, drug history and allergies. Careful attention must be paid to the patient’s ability to understand and follow the instructions
3. Documentation is essential. This creates a record of therapy, patient response and untoward effects. This information can also be used to make changes in policy or to study medical interventions

Question 231

Discuss safe injection practices for medication administration, to include the use of medication from a multi-dose vial

Answer 231

Safe injection practice for medication administration should include methods to ensure safety for both the patient and the nurse:

1. Nurse: Retractable needles and safety caps should be available on syringes. Used syringes and needles should never be recapped manually or bent but should be immediately disposed of in an appropriate secure hazardous waste receptacle
2. Patient: The dosage must be correct and the appropriate route (SQ,IM,IV) and injection technique selected for the medication and the syringe and needle should be the correct size for the volume and with the appropriate needle gauge and length. Multi-dose vials should be used for only one patient. Multi-vials should be kept away from immediate treatment areas if they are to be accessed at different times. When used, the vial septum must be disinfected with 70% isopropyl swab, air dried and, aseptic technique used when obtaining each dose, including a new sterile needle and syringe if multiple doses must be obtained for a patient.

Question 232

Discuss ways that medications can be administered

Answer 232

1. Medications can be administered orally, topically or parenterally. Oral medications are commonly given by mouth, but may need to be administered through a nasogastric tube or other avenue. The nurse must consider the ability of the patient to swallow the substance safely and if the oral route is the most effective way to administer the medication
2. Medications given parenterally are introduced by the subcutaneous, intravenous or intramuscular route. Different medications require different routes of administration. In addition, some decisions about route of administration may depend on how quickly a response is needed to the medication

Question 233

Discuss the use of antacids

Answer 233

1. Antacids act to neutralize the acidic environment in the stomach. These substances usually contain aluminum hydroxide, aluminum phosphate, calcium carbonate or magnesium salts. These are short-acting solutions to deal with gastrointestinal complaints such as heartburn and dyspepsia
2. Caution needs to be taken about educating the patient about possible complications of these medications. Some of the components of these drugs can be absorbed, such as magnesium or calcium. Consideration of other medications and of other medical conditions may determine if an antacid is appropriate. Some antacids may interfere with the absorption of other medications. Antacids may precipitate other complications in individuals with other medical problems, such as heart failure or renal failure

Question 234

Discuss how antibiotics, antiparasitics, antiflatulents and antidiarrheals are used to treat gastrointestinal complaints

Answer 234

1. Antibiotics are used in gastroenterology to treat a number of conditions. Nurses must be familiar with how these drugs work, how they are doses and administered, how they interact with other drugs, and possible side effects
2. Antiparasitic and antifungal agents are used to treat the invasion by parasites or fungi
3. Antidiarrheals are prescribed to control diarrhea. These agents work by inhibiting gastrointestinal activity (opiates), reducing gastrointestinal secretions (peptic-bismol), and/or decreasing the amount of fluid in the waste products (Kaopectate)
4. Antiflatulents are used to treat symptoms produced by gastrointestinal gas

Question 235

Discuss the use of anticholinergics, cholinergics and antiemetics in gastrointestinal medicine

Answer 235

1. Anticholinergics work on both acid secretion and motility. Anticholinergics block the receptors on parietal cells to inhibit acid production. These medications also block nerve impulses that are responsible for smooth muscle tone and contractions. This can result in slower gastric emptying. Side effects include dryness of mucosal surfaces, decreased bladder activity, constipation, and flushing. Anticholinergics should not be used in patients with certain underlying medical conditions
2. Cholinergics promote gastrointestinal motility and secretion. Because of some side effects, such as abdominal cramping, cholinergics have limited applications
3. Antiemetics are prescribed for the control of nausea and vomiting. In general, these substances work on the central nervous system to suppress the vomiting center of the brain

Question 236

Discuss laxatives and cathartics

Answer 236

1. Laxatives and cathartics can lead to bowel evacuation. These substances work in several ways, including increasing intralumenal pressure, stimulation, increasing the bulk of stool, lubrication or softening the stool.
2. Laxatives are used to prepare the bowel for diagnostic studies, such as for colonoscopy. The mucosal surface must be visualized, which requires that the bowel be free of stool. Sometimes these substances promote the elimination of certain materials from the intestine. They are also used to soften the stool and to treat constipation

Question 237

Define: Peptavlon, Chymex, Tensilon, Secretin, Glucagon, Kinevac, Chenix, Actigall, Monooctanoin, Meperidine, Fentanyl, Narcan, Romazicon, Sclerosing agents, Isordil, and Procardia

Answer 237

1. Peptavlon is pentagastrin, a drug used that causes an increase in gastric acid secretion
2. Chymex is bentiromide, which helps evaluate the exocrine function of the pancreas
3. Tensilon is Edrophonium chloride, used to stimulate esophageal spas,
4. Secretin can be administer to investigate the exocrine function of the pancreas
5. Glucagon, which decreases motility, may be used for different procedures
6. Kinevac is cholecystokinin and is used to cause the gallbladder to contract
7. Chenix or chenodeoxycholic acid is used to dissolve cholesterol gallstones
8. Actigall or ursodeoxycholic acid is used to dissolve cholesterol gallstones
9. Monooctanoin is used to dissolve cholesterol gallstones
10. Meperidine or Demerol is a narcotic analgesic that is especially useful in biliary or pancreatic diseases
11. Fentanyl or Sublimaze is a narcotic analgesic associated with less nausea and vomiting
12. Narcan or naloxone is used to reverse sedation and respiratory depression caused by opioids
13. Romazicon or Flumazenil can reverse the sedation of benzodiazepines
14. Sclerosing agents are used to thrombose and fibrose varices
15. Isordil is used to treat esophageal spasm
16. Procardia or nifedipine is a calcium channel blocker used to relax the LES

Question 238

Discuss some of the medications used to treat ulcers

Answer 238

Medications used to treat ulcer disease by reducing the effects of gastric acid or reducing the gastric acid itself

1. H2 blockers or histamine 2 blockers exert their effect on the gastric parietal cell to inhibit acid secretion. Adverse effects may include diarrhea, dizziness or blood dyscrasias
2. Sucralfate acts on duodenal ulcers as a buffer to the effects of gastric acid by covering the mucosa area. The most common adverse outcome is constipation
3. Prostaglandins are prescribed to prevent ulcer formation and to minimize any mucosal disturbances. Side effects include diarrhea and abdominal pain
4. Proton pump inhibitors act to interfere with the formation of gastric acid. People may develop abdominal pain, constipation, diarrhea, vomiting or headaches

Question 239

Discuss some medications to treat inflammatory diseases.

Answer 239

1. Corticosteroids are useful in treating inflammatory disorders of the gastrointestinal tract, such as inflammatory bowel disease. Prolonged use can lead to certain complications, such as hypertension or osteoporosis
2. Immune modulating agents are used to attempt to reduce the exposure to prolonged steroids in patients with inflammatory bowel. These agents have some side effects that need careful monitoring, such as bone marrow suppression
3. Both of the above medications can impede an individual’s ability to fight off infections. It is important for these patients to be up-to-date on all immunizations

Question 240

Discuss medications used to treat pain and to anesthetize patients

Answer 240

1. Narcotic analgesics are used in gastroenterology to treat pain and to premeditate individuals. These agents can mask symptoms, however, so their use requires caution
2. Sedatives and anti anxiety agents are most often used to produce conscious sedation in patients undergoing certain endoscopic procedures. Administration of these agents requires that the patient be carefully monitored through the procedure and after to be sure that vital signs and oxygenation are stable. Patients are at risk of respiratory depression, so equipment for resuscitation must be readily available
3. Reversal agents should also be available. These substances can reverse some of the effects of narcotics or sedatives

Question 241

Define biological and discuss their role in gastroenterology

Answer 241

Biologics are drugs produced from natural sources, such as from cells derived from animals, microorganisms, and plants or through DNA biotechnology. Biologics include monoclonal antibodies, cytokines, enzymes, growth factors and immunomodulators. Biologics that block inflammatory reactions, such as Adalimumab, golimumab, Infliximab, certolizumab and Natalizumab, are used to treat Crohn’s disease and ulcerative colitis, usually if those conditions have not responded to more traditional treatments. These drugs help to bring about and sustain remission. Biologics also have a role in treatment of Clostridium difficile infection and Eosinophilic esophagitis. Biologics are administered IV or SQ and cannot be taken orally. Adverse effects associated with Biologics include local irritation, immunosuppression and increased risk of infection, and increased risk of lymphoma, joint pain and swelling, liver disease, and lupus-like reaction. Biologics may have reduced effectiveness if stopped and restarted because the patient may develop antibodies against the drug

Question 242

Define probiotics and discuss their role in gastroenterology

Answer 242

Probiotics are dietary supplements comprised of bacteria (such as lactobacilli and bifidobacteria) and yeast (Saccharomyces boulardii). Probiotics contain microorganisms that are part of the normal flora of the intestines and can help to restore the balance of microorganisms and improve the metabolism of foods and absorption of nutrients. Probiotics may also reduce colonization of pathogenic organisms. Probiotics that contain Saccharomyces boulardii also may help to reduce toxins produced by Clostridium difficile. Generally, probiotics are well-tolerated but they may cause some abdominal distention and cramping, especially when first taken. Patients who are severely immunocompromised and taking long-term broad spectrum antibiotics have developed sepsis, so probiotics should be used with care in these patients. As with naturally-occurring bacteria and fungi, those in probiotics can be destroyed by antibiotics and fungicides, so probiotics should not be taken within two hours of these types of drugs

Question 243

Describe sedation requirements for different procedures

Answer 243

1. The American society of anesthesiologist defines different levels of anesthesiology that can be used for gastroenterology procedures. These classifications are:
   - minimal sedation: patients respond normally to commands
   - moderate sedation: also known as conscious sedation-state in which patients can respond to verbal stimuli, sometimes requiring stimulation
   - deep sedation: patients cannot be readily aroused without stimuli
   - general anesthesia: patients demonstrate loss of consciousness without arousability. Ventilatory capacity must be monitored carefully
2. Each case is individual and requires careful evaluation and monitoring by the nurse
3. In general, the moderate sedation level or conscious sedation is usually adequate for endoscopic procedures

Question 244

Responsibilities of the gastroenterology nurse for conscious sedation

Answer 244

1. The registered nurse must assess the patient for the ability to communicate and cooperate, underlying medical conditions, predetermined level of comfort, and ability to comply with pre-procedural requirements. The nurse must also ascertain that laboratory studies are within normal limits, that the consent form is signed, that the patient has followed pre-procedural orders and that the patient is aware of the procedure and its complications. Before and during the procedure, the nurse must be certain of the stability of vital signs, such as blood pressure, pulse, oxygen saturation and respiratory rate. These also need to monitored following the procedure
2. Useful but not required are cardiac monitoring or automatic blood pressure monitoring
3. Sometimes, a second nurse is required for those patients with special needs, such as children
4. Documentation is very important. This should be done every 5 minutes during the period of anesthesia administration, then every 15 minutes after sedation. Also, procedures, adverse reactions and therapies must be noted

Question 245

Choosing an intravenous site

Answer 245

1. Much of the choice rests with what is to be administered and for how long. Certainly, a venous site must be chosen. Arteries, unlike venous sites, pulsate. Avoid arteries for IV infusion
2. Saline or heparin locks can be placed to provide access without the administration of continuous IV fluids
3. With an IV infusion, a vein is accessed for the puncture. If a replacement is needed, it should be done proximally to the preceding site. For adults, lower extremity access should be avoid because those areas may be prone to thrombophlebitis. The lower extremity is acceptable for younger patients; infants may even be accessed via scalp veins
4. Documentation of substances given through the intravenous line must be ongoing

Question 246

Introducing an intravenous line

Answer 246

1. The area to be used should be appropriately disinfected. A tourniquet placed proximal to the access site increases the venous pressure so that a vein can be accessed. Gentle palpation across the targeted site can indicated venous tissue. Using the fingers, the vessel can be anchored above and below with the fingers to accommodate the needle. With appropriate insertion, there is a blood return
2. Once the needle has entered the vein, the plastic catheter can be gently advanced. It is then anchored with tape and antiseptic ointment should be applied
3. The site can then be hooked to IV tubing, or a special stop cock can be applied for a heparin lock
4. For removal, after clamping the IV, the catheter is removed. Appropriate pressure and dressing should be applied

Question 247

Complications associated with intravenous therapy

Answer 247

1. Intravenous therapy is associated with some complications. Since the catheter penetrates the skin, there is an increased risk of infection. Careful attention needs to be paid to infection control
2. For long term in-dwelling access, there should be a schedule outlined for changes to reduce the risk of infection. Changing the intravenous equipment may reduce the change of infections
3. If an infection is questioned, cultures should be taken
4. Other possible complications include: hematomas, phlebitis, air embolism, catheter embolism and fluid overload
5. Personnel are also at risk of needle sticks or other exposures to bodily fluids, which may lead to contamination and infection

Question 248

Discuss methods of giving intravenous medication

Answer 248

1. Giving medication intravenously requires that the nurse check the appropriateness of the order, the history of the patient, the compatibility of the medication, and the expiration date of the medicine. The patient’s identity must be ascertained prior to giving the dose
2. The methods of administration can include:
   • continuous infusion, in which the medicine is diluted in a liquid and dripped into the patient over a period of time
   • piggyback method, in which the medication is hooked to the intravenous line in a separate container and given over a short period of time
   • intermittent infusion, in which the intravenous access is maintained via a heparin lock for medications to be given regular intervals
   • IV bolus, in which a discrete amount of medication is pushed over a short time by using an existing access

Question 249

Discuss administering blood products

Answer 249

1. Whole blood can be administered, but fractionated components are preferred. Whole blood can be separated into red cells, platelets, plasma, and clotting factors

• packed red blood cells contain only erythrocytes and are administered for anemia
• platelets are given to those with very low platelets to circumvent bleeding
• plasma is the fluid part of the blood that contains clotting factors without platelets. This is used to treat clotting disorders
• cryoprecipitates are given to people with blood clotting factor deficiencies

2. In administering blood, a filter is used to remove debris found in whole blood and packed cells. The right product must go into the right patient, so careful inspection and documentation is essential. The patient must also be monitored for adverse effects

Question 250

Discuss adverse reactions to blood products

Answer 250

1. Adverse reactions to blood products can occur. These include:

• volume overload, in which the volume load overcomes the ability of heart to pump it. This leads to pulmonary edema
• bacterial reactions from contaminated blood, manifesting as fever, chills and pain
• allergic reactions from exposure to substances in the blood that cause an allergic response
• hemolytic reactions from being exposed to incompatible blood
• subsequent infections from virus contaminated blood

2. Once an adverse reaction is noted, the transfusion should be stopped immediately. After stabilizing the patient, the blood should be returned to the blood bank with documentation of the reaction

Question 251

Define: Hemolysis, vascular access devices, osmosis, PCA, infiltration, leukocyte-poor blood, and phlebitis

Answer 251

1. Hemolysis is the lysis of red blood cells
2. Vascular access devices are for long term use. They include central venous line devices and indwelling infusion ports
3. Osmosis is the process by which solvents pass through a selectively permeable membrane
4. PCA or patient-controlled analgesic devices are patient controlled intravenous access devices for the delivery of pain medication
5. Infiltration occurs when substances from the inserted intravenous line leak into surrounding tissue
6. Leukocyte-poor blood is blood used for prospective transplant patients because it reduces the likelihood of sensitization to tissue antigens
7. Phlebitis is an inflammation of the vein, which can occur as a complication of intravenous therapy

Question 252

Discuss the purpose of infection control

Answer 252

1. The risk of infection must be controlled effectively in gastroenterology. Procedures and treatments increase a patient’s risk of infection. It is important that all equipment be appropriately cleaned, sterilized or disinfected according to standards
2. Earl Spaulding classified devices in the endoscopy suite by level of risk of infection to patients
   • equipment that is used with the intent to disturb the mucosal surface of the gastrointestinal tract is deemed critical and requires sterilization
   • instruments that have contact with skin and mucous membranes are considered semi critical and require high-level disinfection
   • noncritical objects come in contact with skin only and pose a reduced risk of infection. They require intermediate or low-level disinfection

Question 253

Discuss the different levels of infection control

Answer 253

1. Appropriate measures must be taken to keep equipment that comes into contact with patients as clean as possible. There are different demands for preparing different instruments before they are used on patients
2. Some instruments require sterilization, the process of getting rid of all microorganisms. This is accomplished by different methods, such as autoclave (steamed heat), dry heat, use of ethylene oxide at low temperatures, and use of certain disinfectants
3. The process of disinfection can be carried out at several levels
   • High level has the most killing potential, destroying mycobacteria, viruses, fungi and vegetative bacteria
   • To achieve intermediate-level, the process must lead to inactivating M. Tuberculosis, vegetative bacteria, most viruses and most fungi
   • Low-level kills most organisms but does not work against M. Tuberculosis

Question 254

Discuss the standard PPE to be donned during patient procedures

Answer 254

According to CMS guidelines, patient procedures, such as endoscopic examinations, must be carried out under the same standards as surgical operations in a sterile operating/procedure room although most endoscopic procedures, such as a colonoscopy, have been traditionally considered non-sterile. Personal protective equipment (PPE) for sterile environments includes gloves, impervious gown, head and foot coverings, and face mask and face or eye shields. The same PPE is utilized in endoscope reprocessing areas, which should be separate from the procedure room. Some organizations (AORN, AAMI) also require application of clean scrubs provided by the workplace. Hand washing is especially important and should be carried out before gloves are applied and after removal. PPE should be removed and discarded appropriately after a procedure and before leaving the procedure room. For care after the procedure, such as in the recovery area, PPE should be utilized according to risk, but usually includes gown and gloves

Question 255

Outline the appropriate care for issues on the gastroenterology unit: Thermal burns, chemical spills and radiation

Answer 255

Appropriate care for issues on the gastroenterology unit include:

1. Thermal burns: Bipolar probes/electrocautery are used to seal vessels with heat but may cause thermal injury and even perforations of the colon, which require surgical repair. Post-polypectomy, electrocoagulation syndrome (transmural burn but without perforation), which mimics the symptoms of perforations but heals with conservative treatment, may also occur. CT can differentiate the two conditions
2. Chemical spills: Spills may occur in any setting and may be small (up to 300mL), medium (up to 5L), and large (greater than 5L) and may require neutralization and/or absorption with a spill kit. Large spills may require outside assistance. Some spills require alerts and evacuation while others require only restriction from the area of the spill. Material Data Safety Sheets should be consulted for appropriate response
3. Radiation: Patients are often exposed to high levels of ionizing radiation, especially with the increased use of computed tomography and x-rays. Exposure should be limited as much as possible and adequate shielding provided during imaging

Question 256

Discuss the purpose of a “time out” prior to procedure initiation

Answer 256

The pre-surgical/procedural time-out is part of the Joint Commission’s Universal Protocol for preventing surgical/procedural errors. The time-out procedure, which should follow a standard format, follows a completion of pre-procedure verification and marking of the procedure site (if appropriate) and includes:

1. A designated team member initiates the time-out before beginning an invasive procedure/incision
2. All team members who will participate in the procedure must be present and all must communicate during the time-out
3. The entire team must agree that they have the correct patient and the correct site and must agree on the procedure that is scheduled
4. If a patient is scheduled for more than one procedure, a time-out must be called prior to the beginning of all subsequent procedures.
5. If those performing the procedure change during the procedure, for example if another physician takes over, another time-out must be called
6. Each time-out must be documented

Question 257

Discuss reprocessing of accessory equipment

Answer 257

1. Forceps need high level sterilization. These devices need both manual cleaning and manual sterilization
2. Reprocessing the water bottle requires cleaning, lubricating and sterilizing/disinfecting the water bottle . The water bottle consists of the water container, the cap and the tubing that attaches the bottle to the flexible endoscope
3. On a daily basis, the water bottle must be manually cleansed and sterilized/disinfected according to the manufacturers’ specifications. The bottle must be stored dry with no residual liquid or moisture remaining. This will reduce the likelihood of bacterial colonization
4. Sterile water must be used for all endoscopic procedures. During ERCPs, a reprocess water bottle must be used for each procedure. ERCPs have a risk of infections

Question 258

Define bio burden and discuss its significance

Answer 258

Bioburden refers to viable microorganisms that are present on an item, such as an endoscope, before sterilization or present in a liquid. Bioburden is especially a concern in gastroenterology because many nosocomial infections have been endoscopy-associated because of improper reprocessing and disinfection. Bioburden is described in terms of colony-forming units per milliliter (CFU/mL) or total viable count (TVC) of bacteria and fungi and is most often used in reference to Bioburden testing (microbial limit testing) that is carried out on medical supplies and products. However Bioburden may also be used to describe the number of organisms (load and diversity) present in a wound or infection, helping to determine the choice of antibiotic or other treatments and Bioburden is used to describe environmental contamination. For example, a high level of clostridium difficile Bioburden increases the risk of outbreak, and control measures focus on decreasing the Bioburden

Question 259

Summarize the Spaulding Classification for surface sterilization and disinfection

Answer 259

Earle H. Spaulding (1957) devised a classification scheme for disinfection and sterilization of patient care equipment and supplies:

1. Critical items are those that come in contact with sterile tissue and/or the vascular system, including surgical instruments, needles, and angiocaths. These items require sterilization (steam heat, ethylene oxide gas, chemical sterilants) because they carry a high risk of infection
2. Semi-critical items include those that come in contact with mucous membranes and non-intact skin, including anesthesia equipment, respiratory equipment, endocavitary probes, and scopes. These items require high-level disinfection (pasteurization, chemical sterilants, such as >2% glutaraldehyde) to remove all organisms although a small number of spores may remain
3. Noncritical items are those that come in contact with intact skin only and have no contact with mucous membranes, including blood pressure cuffs, urinals, bedpans, and assistive devices. Noncritical items include both those items that come in contact with the patient and with environmental surfaces. These items require intermediate-level (does not destroy spores) to low-level disinfectant (does not destroy spores or mycobacteria)

Question 260

Describe how the endoscope is prepared for cleaning

Answer 260

1. When the endoscope is removed from the patient, the surface of the instrument should be wiped with a cloth freshly prepared with enzyme detergent solution. The cloth should then be disposed of or sterilized/disinfected
2. The distal end of the endoscope should be placed into a container of detergent solution. The solution should be suctioned through the biopsy/suction channel until it appears visibly clear. The detergent suction should be alternated with air suction. The endoscope should then be flushed out or blown out as directed by manufacturer
3. At this point, the endoscope should be detached from the light source and the suction pump. If video equipment is used, affix the protective video cap
4. The endoscope should be inspected for leaks and other damage. The instrument and appropriate parts should be brushed while in the detergent solution
5. The endoscope should be placed in the container and covered, to prevent exposure/spillage

Question 261

Describe how the endoscope is further cleaned

Answer 261

1. The endoscope needs high level disinfection. The instrument must be submerged in the disinfectant for 20 minutes. After the appropriate time, time endoscope channels need to be flushed with air, then thoroughly rinsed. Channels should be flushed with air and then rinsed with alcohol, then flushed with air again. The endoscope should be totally free of chemicals to avoid exposing a future patient to them
2. The most commonly used disinfectant for this purpose is glutaraldehyde
3. Before storage the endoscope should be thoroughly dry to reduce bacterial colonization. The endoscope should be stored vertically
4. There are some automated reprocessors available. Thorough pre-cleaning is still necessary, however. In addition, determining if the automatic reprocessor provides sufficient cleaning for some scopes, such as the ERCP scope, must be ascertained

Question 262

Describe HDL (high disinfection level) disinfection of endoscopes

Answer 262

1. All endoscopes need to undergo HDL disinfection. Choosing which chemical depends on manufacturing guidelines in relation to the endoscope. Personnel should be familiar with SDS/safety data sheets for all of the chemicals
2. Disposal of containers and chemical must be done according to recommendations by the manufacturer. Spill kits need to be available at all times
3. Appropriate personal protective equipment must be worn by staff. These recommendations are given by the manufacturer. An eyewash station must be accessible
4. All of the internal channels need to have a flow of disinfectant. The external surfaces must come in contact with the chemicals
5. A record of all reprocessing should be kept in case of future problems with contamination. Heating and air conditioning vents should be evaluated regularly

Question 263

Compare the processes used for sterilization/disinfection with single use devices versus reusable devices

Answer 263

Single-use devices (suction catheters, stylets, ETTs) are those intended to be discarded as hazardous waste immediately after a single use. These devices typically come in sealed sterile packs and require no further sterilization or disinfection. Some new single-use endoscopes, for example, are disposable and cannot be reprocessed so that the risk of cross-contamination is eliminated. However, some devices are reusable and some single-use devices may legally be reprocessed for additional use. According to the FDA, reprocessing should be done in most circumstances by third-party reprocessors because reprocessing must meet stringent industry standards. Cleaning/reprocessing activities must be done in a separate reprocessing area from the procedure room. Personnel must be throughly trained, and reprocessing should begin immediately after use. The device should be disassembled and parts cleaned with enzymatic detergent, being sure to repeatedly flush and brush all channels to remove all organic material. All brushes or devices used for cleaning should be disposable or disinfected/ sterilized between uses. Ultrasonic cleaning may be used to clean areas that are hard to clean manually. After manual cleaning, devices should receive high-level disinfection by immersion or sterilization as appropriate

Question 264

Define minimal effective concentration in terms of disinfection solutions

Answer 264

The minimal effective concentration of disinfection solutions is the lowest concentration that is effective in destroying pathogenic organisms and/or spores within a specified duration of time. The concentration varies according to the type of disinfectant and whether it is used for high-level or low-level disinfection. Additionally, different concentrations may be needed for different organisms and in different durations of exposure. Examples include:

1. Glutaraldehyde 2%: Contains 1.0% to 1.5% active ingredient, sufficient to destroy pathogens
2. Alcohol: Low-level disinfection only, does not destroy spores or penetrate organic material. Ethyl alcohol at 60-80% is viricidal for lipophilic viruses and some hydrophilic viruses, 95% is effective for M. Tuberculosis, 70% for many bacteria
3. Hypochlorites: 5.25% to 6.15% (equal to 52,000 to 61,500 ppm); 1000ppm needed for M. Tuberculosis, but 100ppm needed for many bacteria and spores and 200 ppm for viruses. 1:10 dilution provides 5250-6150ppm. Common dilutions for disinfection include 1:10 to 1:100
4. Formaldehyde: Sold as formalin at 37% formaldehyde and is effective against bacteria, viruses, fungi, spores, and M. Tuberculosis, but formaldehyde is a carcinogen so exposure and use are limited

Question 265

Discuss general electrical safety practices

Answer 265

1. Electrical safety must be respected. All connections need to be checked regularly, including electrical outlets. Care should be used with flammable materials. Both manufacturers’ instructions concerning equipment and institutional policies should be followed
2. Appropriate fire safety precautions should be taken, including regular checks of safety equipment
3. All equipment should be checked to be certain of normal functioning
4. Precautions need to be taken for patients with allergies, such as to latex, need to be considered. Appropriate precautions need to be taken for patients and personnel alike
5. Preventive measures need to be instituted to reduce accidental injuries

Question 266

Discuss the safety measures when using electrocautery devices

Answer 266

1. Electrocautery uses high-radio-frequency electrical current to cut or coagulate areas in the gastrointestinal tract. The lowest setting possible should be used to accomplish the goals. When not in use, the device should be turned off or set to standby mode
2. The equipment should be checked regularly by appropriate personnel so that it is in good working order. Prior to use in the endoscopy suite, check the integrity of the instrument
3. Bipolar models may be safer since the current returns through the instrument and not the patient. Monopolar models require the appropriate placement of dispersive electrodes or grounding pads fro the respective patient
4. Patient with an implantable defibrillator should have it turned off for the procedure. For patient with pacemakers, special care needs to be taken. The appropriate action should be checked with the patient’s cardiologist, and all manufacturing guidelines should be followed

Question 267

Discuss laser safety

Answer 267

Lasers are used for coagulation and to vaporize tissue. Use of laser equipment can cause fire, skin or eye damage and irritation of the respiratory tract for everyone in the room. Only necessary personnel should be in the room and a warning sign on the door should advise that a laser is in use. Appropriate eye protection should be worn by patients and personnel to protect vision. When not in use, the laser should remain in standby mode. To reduce respiratory exposure, employ smoke evaluators or masks. Move combustible materials away from possible laser contact

Question 268

Discuss safety concerning the use of glutaraldehyde in endoscopy suites

Answer 268

1. For all chemicals: follow label instructions, be familiar with the safety data sheets on these chemicals, and be aware of the spill containment procedure
2. Glutaraldehyde is soluble in water and which can vaporize easily. These properties result in the chemical causing irritation of the eyes and mucous membranes. To minimize exposure, personnel handling glutaraldehyde should wear rubber gloves, goggles, face shield/mask, and an impervious gown. Have access to an eye wash and other washing facilities to flush eyes or wash skin. Was all personal protective equipment before it is used again
3. Use of glutaraldehyde should be restricted to areas with appropriate ventilation to reduce respiratory exposure. Storage requires a cool, dry location. The chemical should be stored in a covered container

Question 269

Discuss the safe handling of body piercings during a gastroenterology procedure

Answer 269

1. Body piercing jewelry should be removed prior to gastroenterology procedures because those on the tongue, lip or nose may interfere with visualization of the airway and may become dislodged and aspirated. Body piercings may conduct electricity, causing burns, if electrocautery is utilized. Piercings may also interfere with imaging, causing artifacts, and cause burns or punctures if left in place during an MRI. Removal procedures vary:
   • nose studs: apply gentle pressure and pull straight out
   • nose screws with curved circle at the end: slowly twist out
   • barbell-type (used on face, lips, genitals, nipples, and navel): unscrew end bead, counter-clockwise
   • enclosed ring (used on face lips, genitals, nipples, and navel): apply pressure inside the ring to force ends apart
   • Labret stems: unscrew end backpiece, counterclockwise
2. Some patients will want the tract maintained. In such cases, sutures or small catheters may be fed through the tract or non-metallic retainers placed if they do not interfere with the procedure or increase risk to the patient

Question 270

Outline the steps needed to minimize radiation exposure in the endoscopy suite

Answer 270

1. The use of X-rays fluoroscopy in the diagnosis of gastrointestinal diseases is very useful. Radiation exposure can be harmful, so minimizing exposure is very important
2. Those in the endoscopy suite are exposed to radiation in three ways: primary, secondary and leakage from the equipment
   
   • primary exposure occurs to the individual being studied. The radiation source is directed at the area to be investigated
   • secondary radiation occurs when the primary radiation scatters or bounces off surfaces. This is the main exposure for the staff in the room
3. Staff members should limit their time in the exam room and allow the greatest possible distance from the source of radiation. Individuals should wear protective gear including a lead apron, thyroid shield, lead glasses, and radioprotective gloves. Shields can be erected around the examination table to reduce exposures. All members with radiation exposure need to wear monitoring equipment to track exposure levels

Question 271

Discuss the proper body mechanics/ergonomics and prevention of repetitive strain injuries

Answer 271

Proper body mechanics/ergonomics and prevention of repetitive strain injury include:

1. Avoid bending at the waist to lift or reach for items. Stoop down with the knees bent
2. Avoid stretching overhead to reach for items on high shelves or out of reach. Use a step stool or grip tool with extension
3. Avoid pushing or pulling with the arms. Use the whole body to relieve strain on the arms and back
4. Avoid reaching, bending, or twisting to lift. Stand close to the person or item to be lifted, bend knees and hips, and use the muscles in the legs to support weight rather than the back or arms
5. Avoid lifting. Use lift devices rather than manually lifting heavy items and patients
6. Avoid prolonged periods of repetitive activity, such as keyboarding or stocking materials and take not of numbness and tingling or discomfort (warning signs) take frequent short breaks

Question 272

Discuss multi drug resistance: Vancomycin resistant enterococci (VRE) and multi-drug resistant organisms (MDRO)

Answer 272

Vancomycin resistant enterococci (VRE) and multi-drug resistant organisms (MDRO), such as multi-drug resistant enterococci, have become severe cause for concern. VRE was first identified in the US in 1989, but by 2004 it was the cause of one-third of all hospital-acquired infections in intensive care units, related to the use of vancomycin. There are several phenotypes, but 2 types are most common in the US: VanA (resistant to vancomycin and teicoplanin) and Van B (resistant to just van VRE) infections are treatable by other antibiotics, but MDRO infections are increasingly resistant to 2 or more antibiotics, including vancomycin. Restriction of vancomycin use alone has not proven successful in controlling development of VRE or MDRO because other antibiotics, such as clindamycin, cephalosporin, aztreonam, Ciprofloxacin, aminoglycoside, and metronidazole are implicated. Prior to antibiotic use is present in almost all patients with MDRO. Other risk factors include prolonged hospitalization and intraabdominal surgery

Question 273

Discuss multidrug resistance Carbapenem-resistant Enterobacteriaceae (CRE)

Answer 273

1. Carbapenem-resistant Enterobacteriaceae (CRE), such as klebsiella sp. and Escherichia coli, are normally found in the human intestinal system but are difficult to treat because of their resistance to almost all (and in some cases, all) antibiotics, resulting in death in up to half of those with bloodstream infections. Enzymes that break down both carbapenems ( a usual target for antibiotics) and antibiotics, rendering them ineffective, include:
   - klebsiella pneumoniae carbapenemase (KPC): most common in the US
   - New Delhi Metallo-beta-lactamase (NDM-1): associated with treatment in Pakistan or India
   - Verona Integron-Mediated Metallo-beta-lactamase (VIM): found in pseudomonas
   - Imipenemase Metallo-beta lactamase (IMP)
2. Infections are associated with patients who have exposure to healthcare settings, such as hospitals and long-term care facilities; invasive medical devices, such as mechanical ventilators and catheters; and long term antibiotic treatment. CRE is easily transmitted person-to-person, especially with contact with fecal material or open wounds. Some patients may be colonized but asymptomatic. CRE may be transmitted with inadequately sterilized endoscopes

Question 274

Discuss important elements of patient education regarding Crohn’s disease

Answer 274

Important elements of patient education for patients with Crohn;s disease (regional ileitis) includes:

1. Patients need to know the usual signs and symptoms and progression of the disease (diarrhea, anemia, abdominal pain, nausea and vomiting, malabsorption, fever, night sweats, and perirectal abscess/fistula) as well as common treatments (steroids, antibiotics, immunomodulatory agents, antidiarrheals, aminosalicylates, tumor necrosis factor antagonists and enteral feedings or TPN)
2. Patients should understand possible adverse effects associated with treatment and be alert for complications
3. Patient should be aware of the pattern of flare ups and remission that is common to Crohn’s disease and other problems that may occur, such as aphthous stomatitis, inflammation of the joints and eyes and anal fissures, fistulas, and ulcerations
4. Patients must be aware of lifestyle changes that may help to reduce symptoms and flare ups, such as avoiding NSAIDs, exercising regularly, and stopping smoking. Patients should be aware of increased risk of colon cancer

Question 275

Discuss important elements of patient education regarding the following: C.diff, VRE, and CRE

Answer 275

Clostridium difficile (C.diff), vancomycin-resistant enterococci (VRE) and Carbapenem-resistant Enterobacteriaceae (CRE) result in healthcare associated infections. Important elements of patient education include:

1. Cause of the infection: Infections occur in those exposed to healthcare settings, invasive medical devices, and/or long-term or repeated antibiotic therapy. C.diff is caused associated with clindamycin and cephalosporins although all antibiotics have been implicated. VRE and CRE may result from almost all antibiotics
2. Signs and symptoms: C.diff results in severe diarrhea but may progress to sepsis. Both CRE and VRE may result in many different types of life-threatening infections (pneumonia, sepsis, UTI, wound infection)
3. Transmission: Some patients infected with these organisms are asymptomatic but may still spread the infection to others. Infection spreads primarily though contact with fecal material, most often on the hands
4. Preventive measures: Patients must take antibiotics only as prescribed and should avoid asking for unnecessary antibiotic prescriptions. Careful hand washing by the patient and caregivers is essential

Question 276

Discuss the transmission of Hepatitis C and proper transmission prevention protocols

Answer 276

Hepatitis C virus (HCV) binds to receptors on hepatic cells and enters to begin replicating. HCV readily mutates, which helps it to evade the host’s immune response. There is no vaccine. HCV is transmitted directly through blood or items, such as shared needles, contaminated with blood. It can also be spread by sexual contact, tattooing and piercing. HCV causes an acute infection (first 6 months) , but 75-85% develop chronic infection. Patients are also at increased risk of liver cancer and HCV is the primary reasons for liver transplants. Nosocomial infections are similar to HBV and related to contaminated blood sampling equipment, multi dose vials, improperly sterilized equipment, and breakdown in infection control methods, so proper use of contact precautions is essential as is educating patients about avoidance of sharing needles and importance of using condoms. New antiviral treatments are up to 90% effective in treating HCV, but there are 6HCV genotypes, and different medications target different genotypes. Options include Daklinza, Zepatier, Mavyret, Harvoni, and Technivie