Week 6: GI Disorders Flashcards
What are normal age-related changes to the GI system (excluding stomach and intestines)?
- Loss of teeth
- Decreased saliva production
- Thicker mucous production
- Diminished sense of taste
- Presbyesophagus
- Production and flow of bile decreases (gallstones likely to form)
Presbyesophagus
Strength of esophageal contractions and the tension in the upper esophageal sphincter decreases.
Effects of Presbyesophagus
- Many experience difficulty swallowing (dysphagia)
- Heartburn caused by stomach acid entering the esophagus d/t weakened esophageal sphincter.
Decrease in smooth muscle along majority of GI tract can cause
Food to move more slowly as contractions necessary for movement and breakdown become weaker.
Normal age-related changes to the stomach
- Stomach lining’s capacity to resist damage decreases -> increases the risk for PUD
- Cannot accommodate as much food (d/t decreased elasticity)
- Decreased rate at which the stomach empties food into the small intestine.
- Aging has little effect on secretion of stomach juices (however conditions that decrease acid secretion is common)
Normal age-related changes to the small intestine
- Movement of contents through the small intestine and absorption of most nutrients do not change much.
- Lactase levels decrease leading to intolerance of dairy products
- Excessive growth of certain bacteria is common -> pain, bloating and weight loss
- Bacterial overgrowth can cause decreased absorption of certain nutrients such as vitamin B12, iron and calcium.
Normal age-related changes of the pancreas
- Decreases in overall weight and some tissue is replaced by scarring (fibrosis)
- Number of secretory cells decreases resulting in a decrease in the level of fat digestion.
Normal age-related changes to the large intestines
- Does not undergo much change
- Rectum does enlarge somewhat -> constipation becomes more common.
Normal-age related changes to the liver
- Liver’s ability to withstand stress decreases
- Repair of damaged liver is slower
- Liver size and blood flow decreases (however liver function tests generally remain normal)
- Ability of the liver to metabolize many substances decreases (some drugs are not inactivated as quickly)
GERD
- Acidic gastric secretions reflux causing irritation and inflammation
- Gastric secretions can include pepsin, intestinal enzymes and bile salts which can be corrosive to esophageal mucosa.
GERD: Degree of inflammation depends on what factors?
- Amount and composition of gastric reflux
- Ability of esophagus to clear acidic contents
Pathophysiology of GERD
Results when defenses of esophagus are overwhelmed by the reflux of acidic gastric contents into the lower esophagus
What are other causes of GERD?
- Incompetent lower esophageal sphincter (LES)
- Decreased LES pressure
- Decreased gastric emptying
- Obesity and smoking
- Hiatal hernia
Clinical Manifestations of GERD
- Heartburn (most common)
- Dyspepsia
- Hyperslaivation
- Non-cardiac chest pain
- Regurgitation
Dyspepsia
Pain or discomfort centered in upper abdomen
What are age related changes that may lead to GERD?
- Decreased salivary secretions
- Diminished esophageal mucosal resistance
- Decline in esophageal motility and clearance
- Loss of Lower Esophageal Sphincter (LES) tone
- Delayed gastric emptying
What is used to diagnose GERD?
Endoscopy which remains the GOLD standard for diagnosing GERD
Symptoms of GERD in older adults: Older adults present with
- Decreased complaints of heartburn, regurgitation and chest pain.
- Increased complaints of dysphagia, respiratory symptoms, vomiting and anorexia.
What are complications of GERD?
- Esophagitis
- Barrett’s esophagus
- Respiratory Complications
Esophagitis can lead to
Scar tissue formation, stricture and dysphagia
Barrett’ esophagus can lead to
Precancerous lesion
GERD: Respiratory complications include
- Chronic cough
- Bronchospasm
- Laryngospasm d/t irritation of the upper airway from gastric secretions.
GERD: Drug therapy
- PPI (omeprazole)
- H2 Blockers (Ranitidine)
GERD: Surgery
Nissan and toupee fundoplications
GERD: Lifestyle modifications
- Weight reduction
- Smoking cessation
GERD: Nutritional Therapy
- Decrease high-fat foods
- Fluids between rather than with meals
- Avoid late-night snacking or meals
GERD: Patient teaching
- Avoid factors that cause reflux (smoking, alcohol, caffeine, acidic/spicy foods)
- Weight reduction, if appropriate
- Small frequent meals
- Elevate the head of the bed
- Eat the last meal 3 hours before going to bed
- Avoid tight clothing around the waist
Peptic Ulcer Disease
Erosion of GI mucosa resulting from digestive action of hydrochloric acid and pepsin.
Peptic Ulcer Disease: What are causes?
- H. Pylori
- Medications: NSAIDs, corticosteroids, anticoagulants, SSRIs
- Lifestyle factors: alcohol, coffee, stress, depression, smoking (delays healing)
PUD develops only in
- The presence of an acid environment
- Excess hydrochloric acid may not be necessary for ulcer development.
Ulcer development can occur in:
- Lower esophagus
- Stomach
- Duodenum
- Margin of gastrojejunal anastomosis after surgical procedures
How can H. Pylori cause PUD?
- In one possible scenario, H. pylori alters gastric secretion and produces tissue damage, leading to PUD.
- In another possible scenario, H. pylori leads to metaplasia in the stomach resulting in chronic atrophic gastritis and in some cases stomach cancer.
The response to H. Pylori is influenced by a variety of factors including
Genetics, environment and diet.
How do medications such as NSAIDs and aspirin cause PUD?
- Inhibit prostaglandin synthesis
- Increase gastric acid secretion
- Reduce integrity of the mucosal barrier
- Responsible for majority of non-H. pylori peptic ulcers
- NSAIDs in presence of H. pylori increase risk of PUD
How do corticosteroids cause PUD?
- ↓ Rate of mucosal cell renewal
- ↓ Protective effects
How do lifestyle factors such as smoking and alcohol/coffee cause PUD?
Alcohol and coffee stimulate acid secretion
Smoking and psychologic distress
Types of PUD
- Gastric or Duodenal (differ in their incidence and presentation)
- Acute or Chronic (depends on degree/duration of mucosal involvement)
Acute PUD
- Superficial erosion
- Minimal inflammation
- Short duration: resolves quickly when cause is identified and removed
Chronic PUD
- Long duration
- Muscular wall erosion with formation of fibrous tissue
- Present continuously for many months or intermittently throughout person’s lifetime
- More common than acute erosions
Gastric Ulcers
- Occur in any portion of stomach; most commonly found in the antrum
- Less common than duodenal ulcers
- More likely than duodenal ulcers to result in hemorrhage, perforation, and obstruction
- Live threatening
Risk factors for gastric ulcers
- H.pylori
- Medications
- Bile reflux
- Alcohol use and smoking
Gastric Ulcer Pain
- Generally high in epigastrium
- 1–2 hours after meals
- “Burning” or “gaseous”
- Food aggravates pain if ulcer has eroded through gastric mucosa
Duodenal Ulcers
- Most common
- Most often caused by h.pylori
- Associated with increased hydrochloric acid secretion.
- Alcohol ingestion and smoking associated with formation.
What can increase the risk of duodenal ulcers?
COPD Cirrhosis of liver Chronic pancreatitis Hyperparathyroidism Chronic kidney disease Zollinger-Ellison syndrome (rare condition characterized by severe peptic ulceration and hydrochloric acid hypersecretion)
Symptoms of duodenal ulcers occur when
gastric acid comes in contact with the ulcer
Clinical manifestations duodenal ulcers
- Mid-epigastric region beneath xiphoid process
- Back pain - if ulcer is located in posterior aspect
- Some experience bloating, N/V and early feelings of fullness.
- Weight gain
Duodenal Ulcer Pain
- 2-5 hours after meals
- “burning” or “cramplike”
- Tendency to occur, then disappear, then occur again.
- Pain relieved by meal.
- Worst at night
Medical regimen for PUD consists of
- Adequate rest
- Dietary modification
- Drug therapy
- Elimination of smoking and alcohol
- Long-term follow-up care
- Stress management
Aim of treatment program for PUD
- Reduce degree of gastric acidity
- Enhance mucosal defense mechanisms
- Minimize harmful effects on mucosa
PUD Drug Therapy
- Antibiotics: to eliminate H. Pylori infection.
- PPI
- H2 receptor blockers
- Antacids
How long does PUD take to heal?
-Complete healing may take 3-9 weeks. (Should be assessed by endoscopic examination)
Complications of PUD
-Hemorrhage
-Perforation
-Gastric outlet obstruction
All of which are considered emergency situations.
Peptic Ulcer Disease: Health Promotion
- Identify patients at risk
- NSAID users among older adults
- Early detection and treatment
- Encourage patients to take ulcerogenic drugs (i.e. NSAIDs, corticosteroids) with food or milk
- Teach to report symptoms related to gastric irritation to health care provider
PUD: Surgical Therapy
- Billroth I or II
- Vagotomy- to decrease acid secretion
- Pyloroplasty- Pyloric Sphincter enlargement
Dumping Syndrome
…
Diverticula
- Small, bulging pouches that can form in the lining of the digestive tract.
- Found most often in the lower part of large intestine (colon).
Diverticulitis
- Inflammation or infection in one or more small pouches in the digestive tract.
- Most commonly found in the left descending sigmoid colon.
Causes of Diverticulitis include
Diet low in fiber and high in refined carbohydrates
Pathophysiology of Diverticulitis
Normal bowel flora overgrow in pouch + feces entrapped -> inflammation -> obstruction of diverticular opening -> trapped infection.
Symptoms of Diverticulosis include
- Abdominal pain
- Bloating
- Flatulence
- Changes in bowel habits
*Frail older adults may not exhibit any of these symptoms
Symptoms of Diverticulitis
- Acute LLQ abdominal pain
- Palpable abdominal mass
- Systemic symptoms of infection
*Frail older adults may not exhibit any of these symptoms
Diverticulosis/Diverticulitis Diagnostic
- Hx and physical
- Barium enema
- Colonoscopy
- Abdominal X-ray
- CT scan with oral contrast
Nursing Care for Diverticulosis include
- High Fiber diet
- Dietary Fiber supplements
- Stool softeners (Colace)
- Activity as tolerated
- Weight reduction (if applicable)
Diverticulitis Nursing Care include
- NPO status- let the colon rest
- IV fluids
- IV antibiotics (Fluoroquinolone and Metronidazole)
- Surgery- abscess or obstruction; resection of colon and temporary diverting colostomy
Diarrhea
The passage of at least 3 loose or liquid stools per day.
It is considered chronic if it’s more than 30 days.
Causes of Diarrhea include
- Virus (norovirus, rota virus)
- Bacteria (e.coli, c-diff, salmonella)
- Food poisoning; contaminated food
- Medications (ABT)
- Lactose intolerance
Diarrhea caused by E. coli
-Watery or bloody diarrhea
-Abdominal cramps
-N & V
-Possible fever
> 60 hours
Diarrhea caused by salmonella
-Fever
-Abdominal cramps
4-7 days
(undercooked poultry)
Diarrhea caused by C-diff
- Watery diarrhea
- Fever
- Anorexia
- Nausea
- Abdominal pain
Diarrhea caused by Giardia lamblia
- Abdominal cramps
- Nausea
- May interfere with nutrient absorption
Diarrhea caused by food intolerance
large amount of undigested food; lactose intolerance and certain laxatives
Symptoms of Diarrhea
- Urgency
- Cramping
- Bloating
- Incontinence
- Pain on defecation
- Presence of blood in the stool
Diarrhea Assessment
- Interview
- Physical Examination
- Stool cultures
Diarrhea Management
-Antidiarrheal agents as appropriate (Lomotil, Imodium AD)
-Soluble fiber
Antibiotic Therapy Associated Diarrhea
- Health care associated infection; patient to patient
- Occurs during or shortly after administration of antibiotics
Antibiotic Therapy Associated Diarrhea is caused by
Clostridium difficile → bowel inflammation + epithelial necrosis -> diarrhea + pseudomembranous colitis
Antibiotic Therapy Associated Diarrhea Symptoms
- Watery non-bloody diarrhea (differing degrees)
- Lower abdominal pain and cramping
- Low-grade fever
- Can lead to dehydration, hypotension and colonic perforation
C-diff Diagnosis
Stool analysis
C-diff Treatment
-Metronidazole (Flagyl) 250 mg QID for 7 to 10 days (Flagyl)
-If refractory, then Vancomycin 125 mg QID for 7 to 14 days
For patients with c-diff, you need to remember
- Hand hygiene (soap and water)
- Address hypovolemia
- Contact precautions
Symptoms of Constipation
- Two or fewer stools per week
- Straining during defecation
- Feeling of incomplete evacuation
Causes of Constipation include
- insufficient dietary fiber
- inadequate fluid intake
- decreased physical activity
- ignoring defecation urge
- medications (particularly opioids)
Complications of Constipation include
- Intestinal obstruction
- Colonic ulceration
- Overflow incontinence with stool leakage
- Excessive straining
Constipation: Excessive straining can cause
- Syncope
- Transient ischemic attacks
- Anal fissures
- Rectal prolapse
Assessment for Constipation
- Carefully evaluate the complaint
- Interview
- Review of Medications
- Physical examination (presence of bleeding, hemorrhoids)
Constipation: Interview questions include
- Frequency of bowel movement (fewer than 3 per week)
- Consistency of stool (hard or difficult to pass)
- Presence of excessive straining (repeated Valsava maneuvers)
- Feeling of fullness in the rectum after bowel movement
- Presence of bright red blood
Constipation patient teaching
- Education- fruits and vegetables; grains; whole wheat and bran
- Hydration
- Increased mobility
- Fiber supplementation (20-35 grams/day)
- Educate the older adult not to depend on laxatives and enemas.
Constipation medication includes
Bulk laxative
Stool softeners
Magnesium-containing laxatives (harmful if in renal failure)
Constipation: Patient and Caregiving Teaching
Read Table 42.9 pg. 937 (Lewis et. Al textbook)
